At-Fault Accident Surcharges for Personal Automobile Insurance
This document provides detailed information on at-fault accident surcharges for personal automobile insurance policies in Massachusetts. It covers the rules and regulations regarding fault determination, premium impact, and the appeal process. It is an essential guide for understanding how at-fault accidents can affect your insurance costs.
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How do I fill this out?
To fill out this file, begin by carefully reading the instructions provided. Gather all necessary information and documentation related to the accident and your insurance policy. Follow the step-by-step instructions to complete the form accurately.

How to fill out the At-Fault Accident Surcharges for Personal Automobile Insurance?
1
Read the instructions carefully.
2
Gather necessary information and documentation.
3
Follow the step-by-step instructions.
4
Complete the form accurately.
5
Submit the form as required.
Who needs the At-Fault Accident Surcharges for Personal Automobile Insurance?
1
Drivers involved in an accident to understand fault determination.
2
Policyholders looking to understand their insurance premium changes.
3
Individuals preparing to appeal an at-fault determination.
4
Insurance agents assisting clients with accident-related queries.
5
Legal professionals handling motor vehicle accident cases.
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What are the instructions for submitting this form?
To submit this form, complete all required fields accurately and attach any necessary documentation. Email the completed form to the Division of Insurance at doa@mass.gov, or submit it via the online submission form on the Division of Insurance website. Alternatively, you can send the form by mail to the Division of Insurance, 1000 Washington Street, Suite 810, Boston, MA 02118-6200. Ensure that you submit the form within the specified deadline to avoid any delays or negative impacts. My advice is to double-check all information for accuracy before submission.
What are the important dates for this form in 2024 and 2025?
The important dates for this form include the accident date, the date the insurer sends the at-fault notice, and the deadline for filing an appeal, which is within 30 days of the notice.

What is the purpose of this form?
The purpose of this form is to provide detailed information on at-fault accident surcharges for personal automobile insurance policies in Massachusetts. It helps policyholders understand how fault determination affects insurance premiums and outlines the process for disputing an at-fault determination. Additionally, it serves as a valuable resource for drivers, insurance agents, and legal professionals in handling accident-related insurance queries.

Tell me about this form and its components and fields line-by-line.

- 1. Accident Date: The date when the accident occurred.
- 2. Insurer Notice Date: The date when the insurer sent the at-fault notice.
- 3. Policy Number: The insurance policy number related to the accident.
- 4. Driver Information: Details about the driver involved in the accident.
- 5. Accident Details: A comprehensive description of how the accident happened.
What happens if I fail to submit this form?
Failure to submit this form can result in the at-fault determination affecting your insurance premium. Ensure timely submission to avoid any negative impacts.
- Increased Premiums: Not submitting the form may lead to higher insurance premiums.
- Loss of Appeal Opportunity: Failure to submit on time means you lose the chance to appeal the at-fault determination.
How do I know when to use this form?

- 1. Accident Involvement: When you have been involved in an accident and need to report details.
- 2. Appealing Fault: When you believe you are not more than 50% at-fault and want to appeal.
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Can I appeal an at-fault determination using this file?
Yes, the file includes information on how to appeal an at-fault determination.
Will my insurance premium go up if I am at-fault?
In many instances, your premium will increase if you are found to be at-fault in an accident.
Who determines who is at-fault in an accident?
Ultimately, the determination of fault rests with the Massachusetts courts.
How can I find out if I am at-fault in an accident?
Your insurer will send a notice to your home if you are presumed to be at-fault.
Does filing an appeal prevent the at-fault accident from affecting my insurance premium?
No, but if the appeal is successful, your insurer must refund any premiums associated with that accident.
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