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




Full Name

Street Address

City

County

State

Zip Code

Do you currently own or rent your residence?

How long have you lived at this address?

If garaging location is different than mailing address, please provide address info:

Home Phone Number

Mobile Phone Number

Email address

How many years of continuous automobile insurance coverage have you had ? If none, state none.

Who is your current automobile insurance carrier? If none, state none.

When does your personal auto policy expire?

How many years have you been with this carrier?

Are you being / have you been cancelled by this carrier?

Have you had a lapse in coverage?

How long have you been without automobile coverage? If no lapse, answer no lapse.

If you had a lapse in coverage, please tell us why you had a lapse:

For discount purposes, who is your current homeowners carrier and what is the policy #?

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:

Driver 5:
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.

If any of the drivers have Good Student, Driver Training or Defensive Driving Courses, copies of the certificates are required to provide the appropriate credits.

For any Accidents, Violations, Suspensions in the last 5 years, provide dates and descriptions regardless of who was at fault. Please provide details in the additional comments box below.

Please email information to ben@zolofrainsurance.com or fax to 732.334.0405.

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 5:
Year:
Make/Model:
VIN #:
Alarm?:
Main Driver:
Was the vehicle new when obtained?

Current approximate odometer reading:
Vehicle #5 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 5:

Please select a Comprehensive Deductible amount for Vehicle 5:

If you own a vehicle that is used in business, please explain in comments section below.

How much Bodily Injury coverage (Liability)?

How much Property Damage coverage?

How much Bodily Injury coverage for Uninsured/Underinsured motorists?

How much Property Damage coverage for Uninsured/Underinsured motorists?

Would you like coverage for towing expenses?

Would you like rental reimburement coverage if your vehicle is not operable?

Would you like the auto carrier to be the primary carrier for medical expenses as a result of an auto accident?

Do you have any other policies with your auto carrier?

Do you have any other household members (including non-licensed)? If yes, please include name and age of individual(s) in comments box below.

If you have another current policy with your auto carrier, please advise what kind of policy and provide policy number (s).

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?

Please provide a copy of your current auto declarations page via email to ben@zolofrainsurance.com or fax to 732.334.0405.

Did we miss something? Enter additional comments below:

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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Contact All Pro
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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