Hollis Insurance Agency, Inc.

1 Village Green North, Suite 121
Plymouth, MA 02360

Phone: 508-209-0400     Fax: 508-209-0444

Name: Expiration Date:
Email Address: Policy #:

New Business


In the new Massachusetts competitive automobile insurance market effective April 1, 2008, 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 https://www.renaissanceins.com/ma-auto-faqs/

Garaging Address:
  If different from mailing address, please explain:
Mailing Address:
Home Phone:
Cell Phone:
Work Phone:
  How would you prefer that we contact you and at what general time?
List vehicles on policy:
Year Make Model VIN#
Do any of the vehicles have anti-theft devices? If YES, which vehicle(s) and what devices(s)?

Are any of the vehicles driven fewer than 7,500 miles per year? Which vehicles?
Are any of the above vehicles a hybrid? If so, which?
Are any of the above vehicles used on a farm? If so, which?
List all drivers in the household:
Name License # Principal Vehicle Driven Out-of-state License # &
Date first received
Do any drivers have their own auto policy or are they listed on another policy? List the policyholder name, company and effective date.
Are any drivers to be excluded from a vehicle? If so, which driver and which vehicle?
Have any drivers attended driver training courses? If so, which drivers?
Have any drivers attended Advanced Driver Training Courses? If so, which drivers and which courses?
Do you have certificate(s) of completion?
Do any of the household drivers currently attend college? If so, who?
Do any college attendees take a vehicle with them to school? If so, which vehicle?
Where is the college located?
Are any drivers college educators? If so, who are they and at which institution?
Do any drivers qualify for a Good Student Discount? They must be on a dean’s list, honor roll, have a Grade B or better average, or must be in upper 20% of the class. Which driver(s) are they, and can you supply a report card?
Please list the insurance companies with which your home, umbrella, boat or business policies are placed if they are not with our agency. Account credits may be offered.
Do you belong to any motor club organizations? Please list club and membership number.
Do any drivers use public transportation? If so, can you provide receipts?
Massachusetts Coverage to be quoted:
Coverage Recommended Limits Limits Requested
Pt 2: Personal Injury $8,000 $8,000
Pt 3: Uninsured Motorist $250,000/$500,000
Pt 4: Damage to Someone Else's Property $250,000
Pt 5: Bodily Injury to Others $250,000/$500,000
Pt 6: Medical Payments $25,000
Pt 7: Collision Damage $500 Deductible
Pt 9: Comprehensive $500 Deductible
Pt 10: Substitute Transportation $45/day-$1,350 maximum
Pt 11: Towing and Labor $100 per disablement
Pt 12: Underinsured Motorist $250,000/$500,000

Each company has its own enhanced coverage. We will offer the available coverage when a quote is supplied.

Thank you for requesting a quote. One of our customer service representatives will respond to you as soon as possible.