Costello Insurance Agency, Inc.

2 South Kimball Street, P. O. Box 5248
Bradford, MA 01835

Phone: 978-374-6352     Fax: 978-521-5127

Name: Expiration Date:
Email Address: Policy #:

With a competitive automobile insurance market in Massachusetts 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.


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



    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. Please provide the vehicle information for the vehicle on your auto policy. If you have more than one vehicle on the this policy please contact us.

    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??



    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.)



    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)?



    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?



    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

    Please mail or fax us a copy of certificate of course completion for verification.

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

    Qualifying guidelines:
    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

    Please mail or fax us the latest copy of academic achievement report for verification.

  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?



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

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



    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 )

    Diminishing Deductibles OEM coverage
    Expanded Rental Additional Towing & Labor
    Loan/Lease Gap Coverage Additional Customized Equipment/Part
  11. Are there any other insurance needs we can help you with now or that you anticipate next year?

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.