Zolofra Insurance
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Toll Free: (888) 858-1777
Fax: (732) 334-0405

Commercial Automobile Online Application

All pro Coverage, Insurance, New Jersey




Insured’s Name (as it should appear on policy)

First and Last Name of the business owner

Street Address

City

County

State

Zip Code

Email

Phone Number

Employer Identification Number (EIN)

Prior Insurance Carrier, if none, state NONE

Prior BI limits, if none, state NONE

Inception/Effective Date (mm/dd/yy) or NEW

Organization Type

Business Type (e.g. plumber, landscaper, gravel hauler)

Year Current Business Was Established

Does Insured Have a GL or BOP Policy?

Financial responsibility will be ordered on all risks. For a corporatoin or partnership, use the name of the President, CEO or partner responsible for the daily operatoins of the business.

Drivers Information:

Driver 1:
Name on License:
DOB:
Social Security Number:
M/F:
Occupation:
Name of Employer:
Education:
In school? If yes, name of school and location:
Marital Status:
Acc/Vio.Susp (Last 5 Years):
DL #:
State and year licensed:

Driver 2:
Name on License:
DOB:
DL #:
Relationship to Driver 1:
Social Security Number:
M/F:
Occupation:
Name of Employer:
Education:
In school? If yes, name of school and location:
Marital Status:
Acc/Vio.Susp (Last 5 Years):
State and year licensed:

Driver 3:
Name on License:
DOB:
DL #:
Relationship to Driver 1:
M/F:
Occupation:
Name of Employer:
Education:
In school? If yes, name of school and location:
Marital Status:
Acc/Vio.Susp (Last 5 Years):
State and year licensed:

Driver 4:
Name on License:
DOB:
DL #:
Relationship to Driver 1:
M/F:
Occupation:
Name of Employer:
Education:
In school? If yes, name of school and location:
Marital Status:
Acc/Vio.Susp (Last 5 Years):
State and year licensed:

For additional drivers, please list same information below.

Vehicles Information:

Vehicle 1:
Year:
Make/Model:
VIN #:
Alarm?:
Main Driver:
Was the vehicle new when obtained?
Current approximate odometer reading:
Vehicle #1 Use

If business or school use, one way daily commute:
Annual Mileage:
Any lease, loan or is this vehicle owned outright?

Name of bank or leasing company if not owned outright:

Please select a Collision Deductible amount for Vehicle 1:

Please select a Comprehensive Deductible amount for Vehicle 1:

Vehicle 2:
Year:
Make/Model:
VIN #:
Alarm?:
Main Driver:
Was the vehicle new when obtained?

Current approximate odometer reading:

Vehicle #2 Use
If business or school use, one way daily commute:
Annual Mileage:
Any lease, loan or is this vehicle owned outright?
Name of bank or leasing company if not owned outright:

Please select a Collision Deductible amount for Vehicle 2:

Please select a Comprehensive Deductible amount for Vehicle 2:

Vehicle 3:
Year:
Make/Model:
VIN #:
Alarm?:
Main Driver:
Was the vehicle new when obtained?

Current approximate odometer reading:
Vehicle #3 Use

If business or school use, one way daily commute:
Annual Mileage:
Any lease, loan or is this vehicle owned outright?

Name of bank or leasing company if not owned outright:

Please select a Collision Deductible amount for Vehicle 3:

Please select a Comprehensive Deductible amount for Vehicle 3:

Vehicle 4:
Year:
Make/Model:
VIN #:
Alarm?:
Main Driver:
Was the vehicle new when obtained?

Current approximate odometer reading:
Vehicle #4 Use

If business or school use, one way daily commute:
Annual Mileage:
Any lease, loan or is this vehicle owned outright?

Name of bank or leasing company if not owned outright:

Please select a Collision Deductible amount for Vehicle 4:

Please select a Comprehensive Deductible amount for Vehicle 4:

Vehicle Type Main Category (Trucks, Trailers, Regular Business, Buses, Motor Homes or Garage Trucks)
Vehicle 1

Vehicle 2

Vehicle 3

Vehicle 4

Specific Vehicle Description (e.g. delivery van, box truck, pickup, van, SUV, tow truck, hearse)
Vehicle 1

Vehicle 2

Vehicle 3

Vehicle 4

Passenger Capacity or # of Axles (for tow trucks, vans, buses ONLY)
Vehicle 1

Vehicle 2

Vehicle 3

Vehicle 4

Trailer Hitch?
 None Vehicle 1 Vehicle 2 Vehicle 3 vehicle 4

Personal Use?
 None Vehicle 1 Vehicle 2 Vehicle 3 vehicle 4

Garaging Zip Code?
Vehicle 1

Vehicle 2

Vehicle 3

Vehicle 4

Current Value- Total Stated Amount (includes permanantly attached equipment)
Vehicle 1

Vehicle 2

Vehicle 3

Vehicle 4

Would you like your spouse to be listed as an additional driver?

Vehicle #1: Maximum Radius of Operation

Vehicle #2: Maximum Radius of Operation

Vehicle #3: Maximum Radius of Operation

Vehicle #4: Maximum Radius of Operation

Bodily Injury/Property Damage Coverage

Uninsured/Underinsured

Personal Injury Protection (PIP)

PIP Deductible

Additional PIP Weekly Benefits (APIP)

Physical Damage Deductible

Would you like excess liability coverage for any non-owned, unlisted vehicles the business has leased, hired, rented or borrowed? (Hired Auto Coverage)

Would you like excess liability coverage for employees using their own vehicles (not listed here) incidentally in the course of the business?

Non-Trucking Liability Coverage (“Bobtail/Deadhead Insurance”)

Trailer Interchange Coverage

On-Hook Towing Liability Coverage

Lastly, an insurance score report and motor vehicle report will be required to deliver an accurate quote. Do we have your permission to obtain both?

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 “Send” 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@allprocoverage.com. Do not “Refresh” the page because all data entered onto the form will be lost.

After you hit the “Send” button, please scroll back down to this area and if successfully sent, a message will appear below. If not successfully sent, a message will appear below which means you have to scroll back up and complete the missing information, which typically involves entering information into a highlighted box. Complete the missing information and then hit “Send” again. Thank you!

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Your First Name (required)

Your Last Name (required)

Your Email (required)

Re-Enter Your Email (required)

Name Of Your Company or type of business if seeking commercial insurance (required)

Street Address (required)

City (required)

County (required)

State (required)

Zip Code (required)

Question (required)

Phone (required)

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Zolofra Insurance Agency
P.O. Box 868
Oakhurst, NJ 07755
Toll Free: (888) 858-1777
Direct: (732) 542-1757
Fax: (732) 334-0405
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