Request for Auto Insurance Quote

Mid-State represents several excellent companies in Massachusetts for your Automobile Insurance needs. We currently offer good driver and group discounts up to 5%.

Please complete the form below and we will contact you with our quote. To assist you with this process, you should have a copy of your current policy in front of you.

Name
Address

	Vehicle 1	Vehicle 2
Make
Model
Year
Bodily Injury to Others	$20,000/$40,000	$20,000/$40,000
Personal Injury Protection	$8,000	$8,000
Uninsured Motorist
Property Damage
Optional Bodily Injury
Medical Payments
Collision	waiver	waiver
Limited Collision
Comprehensive
Substitute Transportation
Towing and Labor
Underinsured Motorist

	Driver 1	Driver 2
Name
Date of Birth
License Number
Years Licensed
Driver Training	Yes	Yes
Percent use of Vehicle One
Percent Use of Vehicle Two

Current Insurance Company
Expiration Date of Policy
Comments Include information on anti-theft, devices, annual mileage, etc
E-mail
Phone

Disclaimer- Please note that all quotes are estimates based on the information given. Your actual quote may vary if the information is incomplete or incorrect.

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Bears on Board

Mid-State Insurance Agency, Inc. is proud to sponsor the local Bears on Board program for Bears on Board Inc. Click here to learn more.

Securities are offered through registered representatives of Sammons Securities Company, LLC. member FINRA(www.finra.org) & SIPC. Securities activities are supervised from a Sammons Securities Company branch office at 4261 Park Rd., Ann Arbor MI 48103. Mid-State Insurance Agency, Inc. is independent of Sammons Securities Co.
37 Mechanic Street - Worcester, MA 01608 Phone: 508-791-5566 \| Fax: 508-755-8720	Copyright Mid-State Insurnace Inc. 2005 All Rights Reserved