Auto Questionnaire

How soon do you need the policy active? *Save 20% for a week or more

Optional: Policy Expiration Date, if you currently have insurance MM/DD/YYYY

How long have you had auto insurance with no gap? *

Is there a company car in the household *

Will any vehicle be used in a ride-sharing program? *

In Auto Information: Put N/A in VIN field to skip

Auto Information *

Year
Make
Model
Annual Miles Driven
VIN or License Plate
Primary Driver
Has a salvage title?

Coverages

Liability Coverage

Vehicle 1 Bodily Injury Coverage *

Vehicle 1 Property Damage - 500K

Difference of $1 from lowest

Vehicle 1 Uninsured Motorist Bodily Injury Coverage *

Protects You

Vehicle 1 Medical Payments *

Protects Your Vehicle

Vehicle 1 Collision Deductible *

Vehicle 1 Comprehensive Deductible Includes Windshields *

Rental Car Coverage *

Are you interested in Roadside Coverage *

Do you have a second auto? (Save Additional 20%) *

In Auto Information: Put N/A in VIN field to skip

Auto Information *

Year
Make
Model
Annual Miles Driven
VIN or License Plate
Primary Driver
Has a salvage title?

2nd Auto Coverages *

Same as first vehicle

Liability only

Seasonal coverage

Do you have a third auto? (Save Additional 20%) *

In Auto Information: Put N/A in VIN field to skip

Auto Information *

Year
Make
Model
Annual Miles Driven
VIN or License Plate
Primary Driver
Has a salvage title?

3rd Auto Coverage *

Same as First Vehicle

Liability Only

Seasonal Coverage

Do you have a fourth auto? (Save Additional 20%) *

In Auto Information: Put N/A in VIN field to skip

Auto Information *

Year
Make
Model
Annual Miles Driven
VIN or License Plate
Primary Driver
Has a salvage title?

4th Auto Coverage *

Same As First Vehicle

Liability Only

Seasonal Coverage

Driving Info

How many claims do you have in the last 5 years? *

Do you have additional drivers in your house besides your spouse who do not have their own insurance policy?

Additional Driver's Information 1 *

First Name
Last Name
Date of Birth
Driver's License
Relation to you

Do you have a 2nd additional driver?

Additional Driver's Information 2 *

First Name
Last Name
Date of Birth
Driver's License
Relation to you

Do you have a 3rd additional driver? *

Additional Driver's Information 3 *

First Name
Last Name
Date of Birth
Driver's License
Relation to you

Do you have a 4th additional driver? *

Additional Driver's Information 4 *

First Name
Last Name
Date of Birth
Driver's License
Relation to you

Thank you

Please press submit to continue.

The Mello Agency serving MA & NH

Securing your today and tomorrow

Liability Coverage

Protects You

Protects Your Vehicle