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124 Main Street
Carver, MA 02330
phone: 508-866-9967
fax: 508-866-9599
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Request a Change: Massachusetts Personal Auto Policy Change
Contact Information
Name *
Address
City, State, Zip
Phone
Fax
Email *
Best Contact Method
Email
Phone
Fax
USMail
Best Time to Call
Policy Information
Policy Number
Company Name
Expiration Date
Effective Date of Change
Driver(s) - List all licensed drivers in your household.
Name on License
Date of Birth
License Number
State
Driver Training
1.
Yes
No
Add
Remove
2.
Yes
No
Add
Remove
3.
Yes
No
Add
Remove
Coverages
Part 3 - Bodily Injury By Uninsured Motorist
50/100
100/500
250/500
500/500
Part 4 - Property Damage
100,000
250,000
Part 5 - Optional Bodily Injury
50/100
100/500
250/500
500/500
Part 6 - Medical Payments
25,000
Part 7 - Collision Deductible
No Coverage
300
500
1,000
Part 9 - Comprehensive Deductible
No Coverage
300
500
1,000
Part 10 - Substitute Transportation
No Coverage
15/day to 450 max
30/day to 900 max
45/day to 1,350 max
Part 11 - Towing & Labor
No Coverage
50/incident
100/incident
Part 12 - Bodily Injury By Underinsured Motorist
50/100
100/500
250/500
500/500
Other
Remove Secured Lender/Lienholder
Principal Place of Garaging
Change Mailing Address to
Change Home Phone Number to
Change Cell Phone Number to
Disclaimer for Form:Please be advised that no coverage can be bound nor any changes made to your policy until confirmed in writing by an employee during regular business hours. If you have not heard from us within 24 hrs (excluding weekends & holidays), please let us know as we may not have received your information.
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