PERSONAL AUTOMOBILE QUOTE REQUEST FORM
FOR AN INSTANT QUOTE USE THE PROGRESSIVE LINK BELOW	...OR You can use this form as a preview of the questions we will ask you about your auto.  If you wish, you can complete and submit the form.  Your inquiry is sent by e-mail and distributed to the appropriate underwriter.  You may contact an underwriter by e-mail or phone at any time - CLICK HERE TO CONTACT US Your quote will be based on the information you provide. If you are interested in our quote, motor vehicle reports will be ordered prior to your application, New Jersey Drivers Licenses are required, vehicles cannot be used for business, additional documentation may be required, and applications must be signed at our office. Most companies impose a mandatory waiting period after application is signed for coverage to be effective. Expect a 2 week delay.
PERSONAL INFORMATION (*Required)
*First Name:	*Last Name:
*Mailing Address:	Apt. or Unit #:
*City:	*State: NJ   *Zip Code:
*County:
*Home Phone:	(area code)
*Work Phone:	(area code)
E-mail address:
*UNDERWRITING  INFORMATION
Are you Insured now? -- Yes No
If yes: Number of years continuously insured: -- Lapsed Less than 1 1 2 3 4 5
Company Name: (enter "none" if expired)
Expiration Date: (or last date insured)
Reason for Quote?	-- First Time Insured Non-Renewed/Cancelled Price New to area Other
Do you own a home or condo? -- Yes No   Do you have a garage? -- Yes No
Do you have current homeowners coverage? -- Yes No

* DRIVER INFORMATION
*DRIVER #1
Name	Birthdate (mm/dd/yy)	Driver Experience	Gender	Marital Status
		New Driver Less Than 3 years 3 - 5 years 6 - 10 years 11 - 15 years 16 - 30 years 31 - 40 years over 40 years	Male Female	Single Married

List MOVING VIOLATIONS for driver #1 within the past 5 years (e.g. speeding 35/25, 11/23/97). If NONE, leave blank:

Describe ACCIDENTS for DRIVER #1 within the past 5 years. If NONE, leave blank:

Accident Prevention Course? (Past 3 Years)   Yes No

	MONTH             YEAR	AT FAULT?	TOTAL DAMAGES
Incident #1	Jan Feb Mar Apr May Jun Jul Aug Sept Oct Nov Dec     1994 1995 1996 1997 1998 1999 2000	Yes No	Less than $300 $300 - $500 More than $500
Incident #2	Jan Feb Mar Apr May Jun Jul Aug Sept Oct Nov Dec     1994 1995 1996 1997 1998 1999 2000	Yes No	Less than $300 $300 - $500 More than $500

DRIVER #2
Name	Birthdate (mm/dd/yy)	Driver Experience	Gender	Marital Status
		New Driver Less Than 3 years 3 - 5 years 6 - 10 years 11 - 15 years 16 - 30 years 31 - 40 years over 40 years	Male Female	Single Married

List MOVING VIOLATIONS for driver #1 within the past 5 years (e.g. speeding 35/25, 11/23/97). If NONE, leave blank:

Describe ACCIDENTS for DRIVER #2 within the past 5 years. If NONE, leave blank:

Accident Prevention Course? (Past 3 Years)   Yes No

MONTH             YEAR

AT FAULT?

TOTAL DAMAGES

Incident #1	Jan Feb Mar Apr May Jun Jul Aug Sept Oct Nov Dec     1994 1995 1996 1997 1998 1999 2000	Yes No	Less than $300 $300 - $500 More than $500
Incident #2	Jan Feb Mar Apr May Jun Jul Aug Sept Oct Nov Dec     1994 1995 1996 1997 1998 1999 2000	Yes No	Less than $300 $300 - $500 More than $500

DRIVER #3
Name	Birthdate (mm/dd/yy)	Driver Experience	Gender	Marital Status

New Driver Less Than 3 years 3 - 5 years 6 - 10 years 11 - 15 years 16 - 30 years 31 - 40 years over 40 years

Male Female

Single Married

List MOVING VIOLATIONS for driver #1 within the past 5 years (e.g. speeding 35/25, 11/23/97). If NONE, leave blank:

Describe ACCIDENTS for DRIVER #3 within the past 5 years. If NONE, leave blank:

Accident Prevention Course? (Past 3 Years)   Yes No

MONTH             YEAR

AT FAULT?

TOTAL DAMAGES

Incident #1	Jan Feb Mar Apr May Jun Jul Aug Sept Oct Nov Dec     1994 1995 1996 1997 1998 1999 2000	Yes No	Less than $300 $300 - $500 More than $500
Incident #2	Jan Feb Mar Apr May Jun Jul Aug Sept Oct Nov Dec     1994 1995 1996 1997 1998 1999 2000	Yes No	Less than $300 $300 - $500 More than $500

VEHICLE INFORMATION
	*CAR 1	CAR 2	CAR 3
Year of Auto
Make (Honda/Ford)
Model (Accord/Escort)
Sub Model (LX, GT, ES)
VIN (necessary for a more accurate estimate)
Name of Principal Driver
Body Style	2 Door 4-Door Convertible Minivan Sport Utility Vehicle Pickup Truck Full-Sized Van	2 Door 4-Door Convertible Minivan Sport Utility Vehicle Pickup Truck Full-Sized Van	2 Door 4-Door Convertible Minivan Sport Utility Vehicle Pickup Truck Full-Sized Van
Type of Use	Pleasure Use Work < 3 mi/1 way Work 3 -10 mi/1 way Work > 10 mi/1 way Business Use 0 - 5000 mi/yr 5001 - 10000 mi/yr 10001 - 15000 mi/yr 15001 - 20000 mi/yr 20001 - 25000 mi/yr 25001 - 30000 mi/yr over 30001 mi/yr	Pleasure Use Work < 3 mi/1 way Work 3 -10 mi/1 way Work > 10 mi/1 way Business Use 0 - 5000 mi/yr 5001 - 10000 mi/yr 10001 - 15000 mi/yr 15001 - 20000 mi/yr 20001 - 25000 mi/yr 25001 - 30000 mi/yr over 30001 mi/yr	Pleasure Use Work < 3 mi/1 way Work 3 -10 mi/1 way Work > 10 mi/1 way Business Use 0 - 5000 mi/yr 5001 - 10000 mi/yr 10001 - 15000 mi/yr 15001 - 20000 mi/yr 20001 - 25000 mi/yr 25001 - 30000 mi/yr over 30001 mi/yr
Air Bags?	Driver's Side Only Both Sides No	Driver's Side Only Both Sides No	Driver's Side Only Both Sides No
ABS Brake System?	Yes No	Yes No	Yes No
Automatic Seat Belts?	Yes No	Yes No	Yes No
Anti-Theft System?	Yes No	Yes No	Yes No
LIABILITY COVERAGES
	CAR 1	CAR 2	CAR 3
Bodily Injury Coverage Limit	$25,000/$50,000 $50,000/$100,000 $100,000/$300,000 $250,000/$500,000	(Liability and Medical limits will be the same for all autos on the policy.)
Property Damage Coverage Limit	$10,000 $25,000 $50,000 $100,000
Uninsured/Underinsured Motorist	$25,000/$50,000 $50,000/$100,000 $100,000/$300,000 $250,000/$500/000
Medical Payments	$10,000
DEDUCTIBLES
Comprehensive Deductible	$0 $50 $100 $250 $500 $1,000 No coverage wanted	$0 $50 $100 $250 $500 $1,000 No coverage wanted	$0 $50 $100 $250 $500 No coverage wanted $1,000
Collision Deductible	$100 $250 $500 $1,000 No coverage wanted	$100 $250 $500 $1,000 No coverage wanted	$100 $250 $500 $1,000 No coverage wanted
OPTIONAL COVERAGES
Towing & Labor