Name(First & Last)

Mailing Address

E-Mail Address 

Phone Number (include area code)

Fax Number

Please contact me by: Phone Mail E-Mail Fax

Business use Personal use

Air bag    Automatic Seatbelt

Anti Theft Device    Vehicle Recovery System

Secured Lender/Lessor    Window Etching

Estimated Annual Mileage Select One Under 5,000 Miles 5,000 - 7,500 Miles Over 7,501 Miles

Driver Number One:

Operator Name

Date of Birth

Driver's License No.

Driver Number Two:

Operator Name

Date of Birth

Driver's License No.

Driver Number Three:

Operator Name

Date of Birth

Driver's License No.

Part 1 - Bodily Injury to Others
This part covers injuries to people who are not in your auto. The state limit is 20,000 per person; 40,000 per accident. This can be increased in part 5: Optional bodily injury to others.
Mandatory - $20,000 per person & $40,000 per accident

Part 2 - Personal Injury Protection
Pays up to 8,000 to you or anyone you let drive your car, anyone living in your household, passengers and pedestrians, no matter who causes the accident.
Mandatory - $8,000 per person

Part 3 - Bodily Injury Caused by an Uninsured Auto
Protects you, anyone you let drive your car, household members, and passengers against losses caused by an uninsured or unidentified driver.
Mandatory - $20,000 per person & $40,000 per accident $20,000 each person & $50,000 each accident $25,000 each person & $50,000 each accident $35,000 each person & $80,000 each accident $50,000 each person & $100,000 each accident $100,000 each person & $300,000 each accident $250,000 each person & $500,000 each accident $500,000 each person & $500,000 each accident $500,000 each person & $1,000,000 each accident

Part 4 - Property Damage to Someone Else's Property
Damage to someone else's property. A Minimum limit of 5000 is required.
Mandatory $5,000 $10,000 $25,000 $50,000 $100,000

Part 5 - Optional Bodily Injury to others
This option extends your liability protection and provides coverage for accidents beyond Massachusetts to anywhere in the United States, it's territories or possessions and Canada.
$20,000 per person & $40,000 per accident $20,000 each person & $50,000 each accident $25,000 each person & $50,000 each accident $35,000 each person & $80,000 each accident $50,000 each person & $100,000 each accident $100,000 each person & $300,000 each accident $250,000 each person & $500,000 each accident $500,000 each person & $500,000 each accident $500,000 each person & $1,000,000 each accident None

Part 6 - Medical Payments
Covers Medical expenses for you, your household members, and passengers regardless of who caused the accident.
$500 (Motorcycle Only) $5,000 $10,000 $15,000 $20,000 $25,000 None

Part 7 - Collision
Pays for collision damage to your car, less any applicable deductible, no matter who causes the accident.
(Option: Waiver of Deductible - If you are not more then 50% at fault and you can identify the other party, the deductible will be waived)
$300 $500 $1,000 $2,000 None Deductible

Part 8 - Limited Collision
Pays for collision damage to your car if you are not more then 50% at fault, and the owner of the other vehicle is identifiable.
None $300 $500 Deductible

Part 9 - Comprehensive Coverage
Pays for damage to or loss of your car, less any applicable deductible (not including collision). Glass coverage is included here at no deductible.
$300 $500 $1,000 $2,000 None Deductible

Part 10 - Substitute Transportation
Reimburse for substitute transportation while your vehicle is undergoing Covered repairs.
$15 per Day / $450 Max. $30 per Day / $900 Max. None Option

Part 11 - Towing and Labor
This part pays for towing and labor charges each time your car becomes disabled whether or not an accident is involved.
$25 per disablemnt $50 per disablemnt None

Part 12 - Bodily Injury Caused by an Underinsured Auto
Pays for bodily injury damages to you, household members and passengers for the injuries caused by an underinsured auto.
(Note: You can only collect for the difference between your policy and the person at faults policy)
$20,000 per person / $40,000 per accident $20,000 per person / $50,000 per accident $25,000 per person / $50,000 per accident $35,000 per person / $80,000 per accident $50,000 per person / $100,000 per accident $100,000 per person / $300,000 per accident $250,000 per person / $500,000 per accident $500,000 per person / $500,000 per accident $500,000 per person / $1,000,000 per accident None

All coverage descriptions are shortened and meant merely as tools to help understand the Massachusetts Automobile Policy.

The McClure Agency representatives are experts in the auto field and can answer any questions you have. Please inquire into our payment options.