Personal Lines

Automobile Rate Quote Information

How many drivers do you wish quoted? 1 2 3 How many vehicles do you wish quoted? 1 2 3 Please note: Applicants requesting quotes for 3 or more drivers/vehicles will be contacted via telephone by a customer service representative to obtain the information for the additional drivers and/or vehicles. Primary Applicant Information First Name: Last Name: Address:       City: State: NJ AK AR AZ CA CO CT DC DE FL GA GU HI IA ID IL IN KS KY LA MA MD ME MI MN MS MO MT NC ND NE NH NJ NM NV NY OH OK OR PA PR PW RI SC SD TN TX UT VA VT WA WI WV WY Zip: Telephone: Gender: Male Female Date of Birth: Marital Status: Married Single Divorced Widowed Date First Licensed: Social Security No: (optional) E-Mail Address: Have you completed at least 2 semesters at a college or university? Yes No Defensive driver training course completed within the last 3 years? Yes No Occupation/Employer:   General Information Are all your vehicles kept at the address entered above? Yes No Are any of your vehicles financed or leased? Yes No Are you a homeowner? Yes No Does your home have a garage? Yes No How many years have you lived at your current address? Do you currently have automobile insurance? Yes No When does your current auto policy expire? How many years have you been continuously insured with your current auto insurance company? Less than 1 2 3 4 5 or more What is the Liability limit on your current auto policy? 15,000/30,000 25,000/50,000 50,000/100,000 100,000/300,000 250,000/500,000 50,000CSL 100,000CSL 300,000CSL 500,000 CSL Other Have you or any driver in your household had auto insurance with NJ Skylands within the last six months? Yes No Are you or your spouse a member of ABCO Federal Credit Union? Yes No Have you or any driver in your household had any accidents in the last 5 years? Yes No Have you or any driver in your household had any convictions or violations in the last 3 years? Yes No Have you or any driver in your household been convicted of driving under the influence of drugs or alcohol in the last 5 years? Yes No Vehicle Information Model Year Make   VIN # Does vehicle have automatic safety equipment (air bags, seat belts)? Yes No Is this vehicle equipped with an anti-lock braking system (ABS)? Yes No Is this vehicle equipped with an anti-theft device? Yes No How many days a week is this vehicle driven to work (including to bus, train or to meet car pool)? 0 1 2 3 4 5 6 7 How many days a week is this vehicle driven to school (including to bus, train or to meet car pool)? 0 1 2 3 4 5 6 7 Is this vehicle regularly used for business other than driving to work or school (i.e. to make deliveries, travel to different job sites, visit clients)? Yes No How many miles is this vehicle driven each way to work? Expected mileage next 12 months Who drives this vehicle the most? Coverage Information Bodily Injury Liability (BI) What's this? 10/10 15/30 25/50 50/100 100/300 250/500 Property Damage Liability (PD) What's this? $5,000 $10,000 $15,000 $20,000 $25,000 $50,000 $100,000 Collision (COLL) What's this? $100 $150 $200 $250 $500 $750 $1,000 $1,500 $2,000 Comprehensive (COMP) What's this? $100 $150 $200 $250 $500 $750 $1,000 $1,500 $2,000 New Jersey Tort Options What's are NJ Tort Options? Limited Tort Full Tort Rental Reimbursement What's this? I decline this coverage $30 per day for 30 days max $40 per day for 30 days max $50 per day for 30 days max Towing & Emergency Roadside Assistance (ERS) NJ Skylands will provide $100 coverage for an authorized service representative to provide: (1) towing of a covered disabled vehicle to the nearest qualified repair facility, or to any facility within 15 miles, and (2) labor (up to one hour) on a covered disabled vehicle at the place of disablement, including battery jump-start, flat tire change, emergency fuel, and locksmith service Personal Injury Protection (PIP) PIP is your medical coverage for injuries you (and others) suffer in an auto accident. PIP pays if you or other persons covered under your policy are injured in an auto accident. PLEASE NOTE QUOTE AUTOMATICALLY INCLUDES: PIP as primary, $250 PIP deductible, $250,000 maximum PIP reimbursement and basic PIP package for income continuation, essential services, death and funeral benefits.