Zolofra Insurance
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Toll Free: (888) 858-1777
Fax: (732) 334-0405
Email: Ben@allprocoverage.com





Name (as listed on policy)

Street Address

City

County

State

Zip Code

Email Address

Best Telephone Number

Date of Accident or Loss (dd/mm/yyyy)

Time of Day of Accident/Loss

AM/PM?
 AM PM

Type of Accident/Claim

Description of Accident/Loss

Name(s) of Injured Parties

Any of the following parties notified?

For Auto Claims, provide the following info: 1. Driver Name, 2. Vehicle Description, 3. Did you receive a ticket? 4. If ticketed, what was it for?

For Property Claims, is the Property habitable?
 Yes No

If Property is not habitable, where are you staying or planning to stay?

Additional Comments

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@zolofrainsurance.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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Zolofra Insurance Agency
P.O. Box 8787
Red Bank, NJ 07701
Toll Free: (888) 858-1777
Direct: (732) 542-1757
Fax: (732) 334-0405
Email: Ben@allprocoverage.com
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