Please take a moment to fill out the form below and one of our representatives will contact you with a free, no-obligation quote. This information will be kept confidential and will be used for quote purposes only. * Please complete the below application in its entirety.
Your Full Name:
Resident Street Address:
Address Line 2
District of Columbia
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
Contact Email Address:
Are you currently an employee of a bank that is a member of the Massachusetts’ Bankers Association and do you earn at least $40K annually?
Number of youthful drivers in your household:
(Defined as individuals under age 21 living in your house and holding a valid Driver's License.)
When would you like coverage to start?
For your convenience, there are 12 monthly enrollment periods – starting on March 1st. To enroll in a given month, you MUST apply and request coverage before 12 midnight the night before the monthly enrollment date. Thus, to enroll in the May 1st period - you must apply and request coverage by midnight on April 30th.
Has any Member of your household had a major driving violation (i.e., DUI, Reckless Driving, etc.) or a license suspension in the past 3 years?
Select Liability Limit & Pricing:
$1M Limit - $255 Annually (plus tax)
$2M Limit - $349 Annually (plus tax)
$3M Limit - $443 Annually (plus tax)
$4M Limit - $538 Annually (plus tax)
$5M Limit - $632 Annually (plus tax)
Do you own any rental properties? Please note that our policy includes coverage for one residential rental property. For coverage to be considered, the rental property must fit under our Policy's definition of "Tenant Property". Here is that definition: "Tenant Property" means a one, two, three or four family dwelling, including a condominium or cooperative in which you hold full legal title either as an individual or as a joint or common tenant with your spouse or "domestic partner" or hold in a trust you created for the purpose of transferring ownership to a family member, while rented to others.:
If you answered "Yes" above that you own rental properties, please provide the following details: How many rental properties, Type of rental property (condo, apartment, dwelling, etc.), # families & # stories in the entire building(s)?
Additional Comments or Questions
You confirm that you currently have (and will maintain) the Required Underlying Insurance.
Review the Required Underlying Insurance
You verify that all of your representations on this application are true and accurate to the best of your knowledge.
A. The surplus lines insurer with whom the insurance was placed is not licensed in Massachusetts and is not subject to Massachusetts regulations; and B. In the event of the insolvency of the surplus lines insurer, losses will not be paid by the state insurance guaranty fund.
Please click the "Submit Application" button to send your quote request. No coverage is in effect until bound by an insurance carrier. This is a request for quotation only.
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November 17th, 2015
Massachusetts & New England Financial Services