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Request Auto Insurance Quote

You may use this convenient online form to request a quote. All fields marked with an asterisk (*) are required fields.

Step 1 - Personal Info

First Name:

Last Name:

Date of Birth:

(mm/dd/yyyy)

Day Phone:

Evening Phone:

E-Mail:

Street:

City:

State:

Zip:

The best way to reach me is:

Daytime Phone Evening Phone
E-Mail Postal Mail

Step 2 - Additional Info

Driver's License #:

When were you first licensed?

(mm/dd/yyyy)

What state were you first licensed in?

Year of Vehicle:

Make:

Model:

V.I.N. # (if available)

Town of Garaging:

Years in Town?

Do you have home, apartment or condominium insurance?
If yes, with which company?

Yes No

Do you own a home?

Yes No

Full time, Good Student?
(B or better avg)

Yes No

Are you a member of any of the following groups?

Are you a member of AAA?

Yes No

Anti-theft Device?
If yes explain type:

Yes No

Estimated Annual Mileage?

Current Company:

Renewal Date:

(mm/dd/yyyy)

Step 3 - Coverage Selections

Physical Damage Coverage (Covers the value of your vehicle if you are at fault in an accident, a victim of a hit & run or if your vehicle suffers fire, theft, or vandalism.)

NO COLLISION COVERAGE / NO COMPREHENSIVE COVERAGE - Due to the age & (lack of) value of my vehicle

$300 DEDUCTIBLES - COLLISION & COMPREHENSIVE COVERAGE.

$500 DEDUCTIBLES - COLLISION & COMPREHENSIVE COVERAGE.

$1000 DEDUCTIBLES - COLLISION & COMPREHENSIVE COVERAGE.

Choose your Liability Limits:

Minimum-type Liability Limits
$20,000 per person/ $40,000 per accident Bodily Injury & Uninsured/Underinsured Motorist Protection $100,000 Property Damage
Basic Protection
$50,000 per person/ $100,000 per accident Bodily Injury & Uninsured/Underinsured Motorist Protection $100,000 Property Damage
Recommended Limits (at least)
$100,000 per person/ $300,000 per accident Bodily Injury & Uninsured/Underinsured Motorist Protection $100,000 Property Damage
Superb Protection*
$250,000 per person/$500,000 per accident Bodily Injury & Uninsured/Underinsured Motorist Protection $100,000 Property Damage *Many people that choose Superb Protection are also interested in carrying a Personal Liability Umbrella Policy. These limits are the underlying requirements for a Personal Liability Umbrella Policy.
Additional Comments or Information:

Thank you for your info. A professional, independent, full service insurance broker will be in touch with you when and where you requested.

Johnson and Rohan Insurance
50 Salem Street ~ P.O. Box 52 ~ Lynnfield, Massachusetts 01940
Phone: 1-800-491-1414 or 1-781-224-0909 ~ Fax: 1-781-224-0546
E-Mail: info@JohnsonandRohan.com