Should you have any questions or any doubt about a change you are contemplating, please call our office during working hours for advice and /or guidance. Effective Date* VEHICLE(S)* Phone #* Cell# Email* I/We,* Understand that I/We can purchase higher limits of liability for my/our Massachusetts motor vehicle policy on, but after careful review I/We have decided to purchase the following limits of liability for each of the following parts listed below: Part 3 - Bodily Injury Caused By Uninsured Auto —Please choose an option—$50,000 per person/$100,000 per accident$100,000 per person/$500,000 per accident$250,000 per person/$500,000 per accident$500,000 per person/$500,000 per accident Part 4 - Damage to Someone Else's Property —Please choose an option—$100,000 per accident$250,000 per accident Part 5 - Optional Bodily Injury to Others —Please choose an option—$50,000 per person/$100,000 per accident$100,000 per person/$500,000 per accident$250,000 per person/$500,000 per accident$500,000 per person/$500,000 per accident Part 6 - Medical Payments —Please choose an option—$5,000$10,000$15,000$25,000 Part 10 - Substitute Transportation —Please choose an option—$15 a day/$450 maximum per loss$30 a day/$900 maximum per loss$45 a day/$1250 maximum per loss$100 a day/$3000 maximum per loss Part 11 - Towing & Labor - per occurrence —Please choose an option—$50$100 Part 12 - Bodily Injury Caused By An Underinsured Auto —Please choose an option—$50,000 per person/$100,000 per accident$100,000 per person/$500,000 per accident$250,000 per person/$500,000 per accident$500,000 per person/$500,000 per accident I/We also wish to or not to carry the following: Collision (contact with vehicles/property) YESNO If, yes Deductible: —Please choose an option—$300$500$1000 Limited Collision (no more than 50% at fault) No Deductible YESNO Comprehensive (fire, theft, glass coverage, vandalism, animal contact) YESNO If, yes Deductible: —Please choose an option—$300$500$1000 Auto Loan/Lease Coverage YESNO New Car Replacement 24 Months (Plymouth Rock Only) YESNO Original Equipment Manufactured Parts (Plymouth Rock Only) YESNO Kids Away at School? YESNO If yes, what school and city/town? Accident Forgiveness? (must be experienced driver with 99 merit rating) YESNO Initials* What Town/City For Garaging? Anti-Theft? YESNO If, yes %: Odometer Reading: Miles Estimated annual mileage? Business Use? YESNO If yes, what type of business and what are the duties of the vehicle? PLATE Type & # If commercial, what is gross vehicle weight? Custom Equipment? YESNO If yes, how much value? Lien holder: Motorcycle CC If truck or Motorcycle Cost New? Listed Operators(* list all household members & any customary operators) Full Name % of use Full Name % of use Full Name % of use Full Name % of use Full Name % of use Full Name % of use ** Check carefully that all operators of your auto(s) are listed above. My insurance agency/agent M. R. Banas Insurance Agency, Inc has made us aware of the fact that I/We may be underinsured or have no coverage at all in many circumstances of possible claims situations of both liability for bodily injury and/or property damage claim(s). I/We understand once my/our liability limits have been exhausted from a claim for bodily injury I/We am/are liable for my/our own defense costs and pre-judgment interest. ** Once the limits of liability have been exhausted the insurance company’s “Duty To Defend” ends. I/We have read this application in its entirety and I/we declare that to the best of my/our knowledge and belief all of the foregoing statements and answers true with no questions regarding its content. I/We instruct M. R. Banas Insurance Agency, Inc. to submit an application for auto insurance on my/our behalf for the above limits of coverage carefully selected by me/us. I agree to the terms above First Name Last Name Date
Banas & Fickert Insurance Agency
