JOSEPH E. SCHINDLER INSURANCE AGENCY
One Wall Street
Burlington, MA. 01803
Phone 781.272.7505
PERSONAL AUTOMOBILE INSURANCE QUOTE
PERSONAL INFORMATION
Your Name
Garaging Address
Garaging City
Garaging State
Zip Code
Daytime Phone
Evening Phone
E-Mail
Most convenient time to call
AM
PM
COVERAGE
Bodily Injury Liability
<Select One>
50/100
100/300
250/500
500/500
Property Damage
<Select One>
25,000
50,000
100,000
Medical Payment
<Select One>
5,000
10,000
15,000
20,000
25,000
50,000
100,000
Uninsured Motorist Liability
<Select One>
50/100
100/300
250/500
500/500
Underinsured Motorist Liability
<Select One>
50/100
100/300
250/500
500/500
Comprehensive Deductible
<Select One>
300
500
1,000
Collision Deductible
<Select One>
300
500
1,000
Rental Reimbursement
<Select One>
$15 a day / 30 days
$30 a day / 30 days
Towing & Labor
<Select One>
$25
$50
Current insurance Company Name
What is your next renewal date
What is your current Annual premium
Have you been canceled or non-renewed
in the past 3 years
Yes
No
VEHICLE INFORMATION
Vehicle #
Year
Make
Model
License Plate Number
License State
Annual Mileage
4-wheel Drive
Yes
No
Alarm System
Yes
No
Air bags
Yes
No
Auto Seatbelts
Yes
No
Own your Home
Yes
No
Driver
<Select One>
Primary
Occasional
Use of Vehicle
<Select One>
Personal
Business
Years Licensed
If under 3 years - driver training?
Yes
No
DRIVER INFORMATION
Driver Number
Name on License
License State
License Number
Date of Birth
Occupation
