Please FAX completed form to Dave at (201) 652-0721
Name: __________________________________ Today’s Date: ____________________
Mailing Address: _____________________________________________________________
Telephone Number(s): HOME ___________ CELL ____________ WORK ____________
Please complete the following on ALL licensed drivers in the household, including drivers who may have their own insurance:
Name Date of Birth Soc. Sec. # Driver’s License # State M/F Year Marital
Licensed Status
Vehicle Information:
Vehicle Year Make Model VIN # Miles to Work Primary Airbag(s) Alarm
Or School Driver
#1 ___________________________________________________________________________
#2 ___________________________________________________________________________
#3 ___________________________________________________________________________
#4 ___________________________________________________________________________
Type of Protective Anti-Lock Where Parked Comprehensive Collision
Device Brakes On/Off Street Deductible Deductible
#1 ___________________________________________________________________________
#2 ___________________________________________________________________________
#3 ___________________________________________________________________________
#4 ___________________________________________________________________________
Are any vehicles used for Business or Farming? ___ If so, which Vehicle(s): 1 2 3 4
Do you presently have Insurance? YES __ NO ___ If NO, date last coverage ended? ________
Prior Insurance Company Name ________________ Reason for Cancellation _______________
How many years have you had continuous insurance? ___________________________________
How did you hear of our Agency? __________________________________________________
All policies will be quoted with liability limits of $100,000/$300,000/$50,000, Comprehensive and Collision deductibles of $500, Verbal Threshold, PIP Limit of $250,000 with a $250 deductible and Additional PIP Option #5 unless other coverages have been requested.
WE WILL NEED TO ORDER AN INSURANCE SCORE FOR QUOTING. PLEASE INITIAL WHERE INDICATED FOR PERMISSION TO ORDER SAID DOCUMENT.
X _________