ZOLOFRA INSURANCE AGENCY

Ready to protect you today for what matters tomorrow.

Personal Auto Form

*Name *Address (#, street, unit #, city, state, zip and county) *Do you currently own or rent your residence? If garaging location is different than mailing address, please provide address info: *Home Phone Number Mobile Phone Number *Email address *Who is your current automobile insurance carrier? If none, state none. When does your personal auto policy expire? How many years have you been with this carrier? *Are you being cancelled by this carrier? If you do not have coverage answer no. *Have you had a lapse in coverage? *How long have you been without automobile coverage? If no lapse, answer no lapse. If you had a lapse in coverage, please tell us why you had a lapse: For discount purposes, who is your current homeowners carrier and what is the policy #? *All Drivers in Household - Information

For additional drivers, please list same information below.

If any of the drivers have Good Student, Driver Training or Defensive Driving Courses, copies of the certificates are required to provide the appropriate credits.

For any Accidents, Violations, Suspensions in the last 5 years, provide dates and descriptions regardless of who was at fault. Please provide details in the aadittional comments box below.

Please email information to ben@zolofrainsurance.com or fax to 732.334.0405.

*Vehicle Information

If any autos are leased or financed, please provide lienholder name and address in comments section below. Please identify vehicle.

If you own a pick-up or van that is used in business, please explain in comments section below.

*Which cars would you like collision coverage?
Car 1
Car 2
Car 3
Car 4
Car 5
NONE
*Which cars would you like comprehensive coverage? (other than collision, or liability) NJ requires 15/30 minimum limits.
Car 1
Car 2
Car 3
Car 4
Car 5
*Which cars do you currently make lease or loan payments on?
Car 1
Car 2
Car 3
Car 4
Car 5
NONE
*How much Bodily Injury coverage? *How much Property Damage coverage? *Please select a Collision Deductible amount: *Please select a Comprehensive Deductible amount: *How much Bodily Injury coverage for Uninsured/Underinsured motorists? NJ requires 15/30 minimum limits. *How much Property Damage coverage for Uninsured/Underinsured motorists? *Would you like coverage for towing expenses? *Would you like rental reimburement coverage if your vehicle is not operable? *Would you like the auto carrier to be the primary carrier for medical expenses as a result of an auto accident? *If you do not have medical coverage currently, would you like the auto carrier to pay for medical expenses incurred in an auto accident? *Do you have any other policies with your auto carrier? *Do you have any other household members? If yes, please include name and age of individual(s) in comments box below. If you have another current policy with your auto carrier, please provide policy number (s).

Please provide the estimated values of the following personal property you own:

Jewlery & Watches:

Furs:

Silver:

Fireams:

Stamp and Coin Collections:

Fine Arts and Breakable Items:

Please provide a copy of your current auto declarations page via email to ben@zolofrainsurance.com or fax to 732.334.0405.

Please advise if you have any Corporate Vehicles. If so, please advise of limits, year, make and model of vehicles(s) in the space provided below.

Did we miss something? Enter additional comments below:

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Disclaimer Notice - The premiums quoted are estimates based on information you provided. This quotation does not constitute a contract of insurance, nor does it provide coverage for any loss or claim. Coverage can only be bound by an agent with a signed application and a down payment.

Please utilize the "Submit" Button to send your form to our office. If the website does not allow you to submit the form, please print the page and fax it to 732.334.0405 or scan it into your computer and send it to ben@zolofrainsurance.com. Do not "Refresh" the page because all data entered onto the form will be lost.