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Chas. F. Hartshorne & Son, Inc.
3 Chestnut Street
Wakefield, MA 01880
781-245-4300
info@hartshorneins.com
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Request for an Auto Insurance Quote
By completing and submitting this form, you agree hat no coverage is bound and no policy is in effect until you are contacted by one of our agency representatives. All information submitted is held in the strictest confidence and is only gathered for the purposes of providing you an insurance quote. To provide the most accurate quote possible, please complete all areas that apply.
 
General Information
Full Name
Address
City
State
ZIP Code
Telephone
Email Address required
Compulsory Coverages
Bodily Injury Liability
Personal Injury Protection (PIP) Self  Household        Deductible 
Uninsured Motorist Liability
Property Damage Liability
Optional Coverages
Medical Payments
Collision Deductible
Limited Collision Deductible
Comprehensive Deductible
Substitute Transportation
Towing and Labor
Underinsured Motorist Liability Cannot be higher than Bodily Injury Liability limit
Driver Information
Driver Number 1 2
Name on License
License Number
License State
Date of Birth
Gender
Male Female
Male Female
Martial Status
Married Single
Divorced Widowed
Married Single
Divorced Widowed
Relationship to Applicant
Occupation
SDIP Step (Safe Driver Insurance Plan)  (if you know it)   (if you know it)
Good Student?
Yes No
Yes No
Driver Training?
Yes No
Yes No
Vehicle Information
Vehicle # 1 2
Year
Make
Model
VIN
License Plate
License State
Garage City/ZIP Code
Garage ZIP Code
Annual Miles Driven
 
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