Auto

Auto

PERSONAL INFORMATION
Name:	First:
	Last:
E-Mail address:
Phone numbers:	Daytime:
	Evening:
	Fax:
How would you prefer to be contacted regarding your quote?	Phone Fax Mail E-mail
Best time to call:
Address:
City:
State:
Zip code:
Do you currently own your home, or rent?	Own Rent
Driver's license number:
Social security number:

DRIVER INFORMATION
	Name:	Relationship to applicant:	Sex:	Marital status:	Driver's age:	Which vehicle does he/she drive?	Percent use:
Driver #1			Male Female	Married Single
Driver #2			Male Female	Married Single
Driver #3			Male Female	Married Single
Driver #4			Male Female	Married Single

DRIVER HISTORY
Current Insurance Company (Not Agency):
Have you or any other driver in your household:
Had a ticket in the last 3 years?	Had a license suspended or revoked in the last 6 years?	Had a financial responsibility filing in the last 6 years?	Made any claims in the last 5 years?
Yes No	Yes No	Yes No	Yes No
If you answered yes to any of the above questions, please explain:

VEHICLE #1 INFORMATION
Year:	Make:	Model:	Vehicle ID# (VIN):

Primary driver:	Annual mileage:	Is the vehicle driven to school or work?	If driven to school or work, how many weeks per month?	If driven to school or work, how many miles one way?
		Yes No	Days Weeks	Miles
Is the vehicle in any way modified or customized?			Is there any existing damage to the vehicle?
Yes No			Yes No
If vehicle is kept at an address other than that listed above, please indicate below:
Address: City: State: Zip:

VEHICLE #2 INFORMATION
Year:	Make:	Model:	Vehicle ID# (VIN):

Primary driver:	Annual mileage:	Is the vehicle driven to school or work?	If driven to school or work, how many weeks per month?	If driven to school or work, how many miles one way?
		Yes No	Days Weeks	Miles
Is the vehicle in any way modified or customized?			Is there any existing damage to the vehicle?
Yes No			Yes No
If vehicle is kept at an address other than that listed above, please indicate below:
Address: City: State: Zip:

VEHICLE #3 INFORMATION
Year:	Make:	Model:	Vehicle ID# (VIN):

Primary driver:	Annual mileage:	Is the vehicle driven to school or work?	If driven to school or work, how many weeks per month?	If driven to school or work, how many miles one way?
		Yes No	Days Weeks	Miles
Is the vehicle in any way modified or customized?			Is there any existing damage to the vehicle?
Yes No			Yes No
If vehicle is kept at an address other than that listed above, please indicate below:
Address: City: State: Zip:

VEHICLE #4 INFORMATION
Year:	Make:	Model:	Vehicle ID# (VIN):

Primary driver:	Annual mileage:	Is the vehicle driven to school or work?	If driven to school or work, how many weeks per month?	If driven to school or work, how many miles one way?
		Yes No	Days Weeks	Miles
Is the vehicle in any way modified or customized?			Is there any existing damage to the vehicle?
Yes No			Yes No
If vehicle is kept at an address other than that listed above, please indicate below:
Address: City: State: Zip:

COVERAGE OPTIONS
Underinsured motorist-property damage:
Underinsured motorist-bodily injury:
Bodily injury liability:
Property damage liability:
Medical-personal injury protection:
Accidental death:

QUESTIONS, COMMENTS OR ADDITIONAL AUTOMOBILE INFORMATION?

Duryea Agency
P.O. Box 278
200 Main Street, Suite C
Glen Gardner, NJ 08826
Phone: 908-537-2000
Email: mailto:admin@duryeaagency.com

Duryea Agency
P.O. Box 518
79 North Main Street
Manahawkin, NJ 08050
Phone: 609-597-7343
Fax: 609-978-0170