In Anticipation of additional discounts you may be eligible for on your upcoming auto policy renewal and in order for us to provide all the new discounts being offered through the insurance industry, we respectfully ask that you complete the below questionnaire and return it to us as soon as possible. This will allow us to continue to make sure we have you correctly placed with the most competitive company for your unique situation, with the broadest coverage, providing the best value for you. At Downey Insurance we value our relationship with you and thank you again for your patronage. As truly independent agents, representing the major auto insurance companies of Massachusetts, we have the capacity to match your individual scenario to the company that works best for you and look forward to doing so.

REQUIRED INFORMATION
Date First Licensed for all household members
Name:		Date:
Name:		Date:
Name:		Date:
Name:		Date:
Do you have a Home/Condo/Renters insurance policy?
	Yes   No
If yes, with what insurance company?
If not with Downey Insurance please fax or email a copy to our agency at 508-485-6463 or info@Downeyinsurance.com.

PRIMARY DRIVER INFORMATION
Name:		Zip:
Address:		Phone:
City:		Drivers Lic.#:
State:		Email:

CHECK ALL THAT APPLY

Existing Discounts

Multi Car Discount - 2 or more insured with same company

Low Mileage Discount - Driving less than 7500 miles annually

AAA Discount - 4%

Anti Theft Discount

MBTA Pass Discount - 11 of the 12 monthly passes that fall             within your policy term

New Discounts - Please check all that may apply:

Loyalty/Renewal Credit - Applied automatically

Hybrid Vehicle - Applied automatically

Student Away at School Credit -             Minimum of 100 miles for home for a full time student

Companion Policy Credit -             Both home and auto insured with same insurance Company

Good Student Credit -             B average or Honor Roll/Deans List student. Verification required

Advanced Driver Training -             In Control Adv. driver training www.wedriveincontrol.com

Submit the Completed Form