M - F, 8:30am - 5:00pm
(617) 389-9400

Discount Protection Survey

Discount Protection Survey
CLIENT INFORMATION
First Name:

Last Name:

Email:

Cell Number:

Work Number:

Occupation:

AUTO PROTECTION QUESTIONS
Does our agency insure ALL of your household cars?:

Have you acquired any new vehicles not listed on your policy?:

Are all licensed drivers in your household listed on your policy?:

Are there any licensed drivers a student with a B or above average?:

Are there any licensed drivers who have taken a defensive driving course?:

Are there any licensed drivers away at school?:

Are there any household members that are active Miliary serving away?:

Are there any hybrid or electric vehicles?:

Are any vehicles garaged at another location?:

Interested in Paying Policy in Full? 3% to 7% savings:

Interested in Automatic Payment from your bank? 1% to 3% savings & Lower Billing Fees:

Are there any non-household residents that normally drive your car?:

Are there any vehicles used in connection with a business?:

HOME PROTECTION QUESTIONS
Does our agency insure ALL of your properties/home?:

Do you have a pool?:

Does your home have a central burglar alarm?:

Does your home have a central fire alarm?:

Do you have a Temperature Monitoring Device?:

Do you run a business from your home?:

Do you own a dog?:

If Yes, What Breed?:

Do you have a Hard-Wired Generator permanently installed?:

Does your Sump Pump have a Battery Backup System?:

Do you have a Water Leak Detection and Control System?:

Have you done any significant renovations or additions in the last 3 years?:

Would you like us to provide you with a Flood Insurance quote?:

Would you like us to provide you with Earthquake Insurance quote?:

DO YOU OWN ANY OF THE FOLLOWING
Check all that apply
Any Collector Items
Art Work
ATV
Baseball Cards
Bicycles (over $1,500)
Cameras (over $1,000)
Furs
Golf Carts
Golf Clubs (over $1,500)
Guns (over $3000)
Jet Ski
Jewelry (over $5,000)
Moped
Musical Instruments
Silverware (over $1,000)
Snowmobile
HOUSEHOLD UPDATES
What year was your heating and cooling system last updated?:

What year was your roof last replaced?:

What year was your plumbing replaced?:

What year was your electric last updated?:

GENERAL QUESTIONS
Do you have any specific questions on an area of insurance that we may research for you? Comments:

Do you have any suggestions on how we could improve the Agencys Service?:

Do you have any specific expectations or special requests we may work on for you?:

Other than price, what is most important to you when it comes to Insurance? Please select a number 1 through 4 (1 being the most important)
Agency Service:

Insurance Company:

Protection of Assets:

Claim Service:

The following organizations offer insurance discounts. Please state if you have donated in the past 12 months to any of the following.
Impact Melanoma:

Pan Mass Challenge:

The Special Olympics:

The Jimmy Fund:





or call
617-389-9400

Everett Office


629 Broadway
Everett, MA 02149
(View Map)

Hours: 8:30am - 5pm, M - F
Phone: 617-389-9400
Fax: 781-584-4445

Burlington Office


1 Mountain Road
Burlington, MA 01803
(View Map)

Hours: 8:30am - 5pm, M - F
Phone: 781-272-8210
Fax: 781-584-4445

Lynnfield Office


220 Broadway Suite #304
Lynnfield, MA 01940
(View Map)

Hours: 8:30am - 5pm, M - F
Phone: 781-596-0033
Fax: 781-584-4445

Malden Office


258 Highland Ave
Malden, MA 02149
(View Map)

Hours: 8:30am - 5pm, M - F
Phone: 781-322-1400
Fax: 781-397-9613