Please Fax Current Coverage Selection Page to (781)894-2072 or Fill Out Form Below and Submit to Powers Insurance Agency. Thank you.

Name: 

Address: 

City: State: Zip: -

Home telephone # : (Please include your area code.)
Work # : Fax # :
Best Time to Reach You: 
E-Mail Address: 



Expiration Date of Current Policy: 

Vehicle Description(s)

Vehicle #1 (Year, Make & Model) Registration #
Vehicle #2 (Year, Make & Model) Registration #
Vehicle #3 (Year, Make & Model) Registration #

Vehicle Use

Vehicle #1 

Vehicle #2 
Vehicle #3 

Drivers Information

Driver #1-Name Date of BirthLicense #
Years Licensed State Drivers TrainingYesNo
Driver #2-Name Date of BirthLicense #
Years Licensed State Drivers TrainingYesNo
Driver #3-Name Date of BirthLicense #
Years Licensed State Drivers TrainingYesNo

Coverages

Uninsured/Underinsured Motorists Limit 

Property Damage 

Liability Limit - Bodily Injury 

Collision Coverage

Comprehensive Coverage

Substitue Transportation Coverage ?
Yes No

Towing & Labor Coverage?
Yes No

AAA Auto Club Member?
YesNo

 

 
 
 


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