Gaudreau-Fountain Ins. Agency, Inc.

946 Main Street
Warren, MA 01083

Phone: 413-436-5000     Fax: 413-436-5251

Name: Expiration Date:
Email Address: Policy #:

As the Massachusetts competitive automobile insurance market enters its second year, there are various coverage options and premium discounts available from different insurance companies.

Please complete and return this survey to us even if you have already answered similar questions on a renewal questionnaire from the insurer of your current auto policy. With this information we can provide you the most appropriate coverage and competitive quotes for your renewal policy.

Please contact us if you have any questions and visit our Frequently Asked Questions http://www.renaissanceins.com/ma-auto-faqs/

 

  1. Other than the insurance you have purchased from our agency, do you have any additional policies with another insurance company or independent agency?

    Yes

    No

    a. If yes, check all that apply and provide the name of the insurance company (not the agency) on your policies

    Homeowners Ins. Company:
    Condominium Ins. Company:
    Renter's Insurance Ins. Company:
    Auto Policy - Number of Vehicles Insured: Ins. Company:
  2. Is any vehicle listed on your automobile policy driven fewer than 7,500 miles per year?

    Yes

    No

    a. If yes, please fill out the following information:  
    Vehicle Yr.: Vehicle Model:
    Approximate number of miles driven per year:
    Current odometer reading:
  3. Are you a member of AAA Motor Club or Other Motor Club??

    Yes

    No

    a. If yes, please fill out the following information:  
    Name oF Motor Club: Membership #:
    Member's Name:
    Month and Year Activated:
  4. Do you have an SBLI life insurance policy? (an auto insurance premium discount may be available to SBLI life insurance policy holders, this information will not be used to contact you for any sales or marketing purpose.)

    Yes

    No

    a. If yes, please fill out the following information:  
    Policy owner's Name  
    Policy effective date
    Policy number:
  5. Are you or any of the drivers on your policy inexperienced operators (drivers licensed less than 6 years)?

    Yes

    No

    If yes, complete questions #6-#8
    If no, skip to question #9

  6. Have any of the inexperienced operators on your policy completed a certified Advanced Driver Training course?

    Yes

    No

    a. If yes, please indicate course taken and provide a certificate of course completion.

    In Control Advanced Driver Training

    Skid School by Stevens Advanced Driver Training

  7. Has the inexperienced operators on your policy, if any, achieved "Good Student" status for academic performance per the following guidelines?

    Qualifying guidelines:
    Provide latest copy of academic achievement report for verification.
    Must be High School, Vocational School, College or University Student who is:

    A student with B or better average

    In the top 20% or his/her class

    A student with a 3.0 or higher grade point average

    On the Honor Roll

    On the Deanís List

  8. Are any inexperienced operators listed on your auto policy currently away at a school more than 100 road miles from your residence (principal place of garaging) without regular access to operate your insured vehicles?

    Yes

    No

    If yes, please provide the inexperienced operator Name(s) and School(s) attending

    Name School
  9. Does anyone in your home utilize public transportation?

    Yes

    No

    a. If yes, please provide Name of approved public Transit System:

    *Business Use is NOT eligible. Must submit a minimum of 11 consecutive months of passes/tickets and proof of purchase for refillable/pre-paid passes.
    (i.e. Charlie Card-copy of bank statement showing charges)

  10. Would you like to receive quotes for optional coverage offered by some insurers for additional premium charges? (refer to our Frequently Asked Questions for detailed descriptions at http://www.renaissanceins.com/ma-auto-faqs/ )

    Diminishing Deductibles OEM coverage
    Expanded Rental Additional Towing & Labor
    Loan/Lease Gap Coverage Additional Customized Equipment/Part

Please be advised that insurance coverage cannot be bound, modified, or terminated by e-mail messages or information provided to us via the web. Any information you submit will be used solely for the purpose of quoting insurance options, and does not in any way constitute an agreement of coverage.