Vehicle Information

1. Year?

2. Make, model and motorcycle CC?

3. Vehicle Identification Number?

4. Date of Purchase? (xx/xx/xx)

5. Was the vehicle? New Used

6. Cost New?

7. Estimated annual mileage?

8. Odometer reading?

9. Air bag/passive seat belt? Yes No

10. Anti-theft? Yes No

11. Vehicle recovery system? Yes No

12. Leased Auto? Yes No

13. Secured Lender and/or Lessor?

Driver Information

1. Operator Name?

2. Date of birth? (xx/xx/xx)

3. Date first licensed? (xx/xx/xx)

Massachusetts

Other

4. Approved driver training? Yes No

5. Owner? Yes No

6. Percent of use? %

7. During the last 6 years have you or any listed operator:

A. Been involved in any motor vehicle accident or been found guilty of any moving violation?
Yes No

B. Been assigned to an alchohol education program?
Yes No

C. Had two or more total fire or total theft losses?
Yes No