I need help with * NJPAIP-NJ Car Insurance Standard NJPAIP-BASIC LIMITED POLICY NJ PAIP Rates are set by the State Dept of Insurance. You wont have to shop around. Select Standard or BASIC [LIMITED]How Many Points DMV/Insurance Points added together? * 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 more than 30 7 or more MVC/DMV and or Insurance points added togetherWere you Canceled MID-TERM more than 30 days? NA YES NO MID Term Cancellations require Non Payment Cancellation Letter.Is Your License SUSPENDED? NO YES Getting Restored If Suspended You will need A Licensed Driver.Any AT-Fault Accidents last 36 months * NO 1 2 3 4 5 6 7 8 9 10 At Fault accidents are 5 insurance points each.Phone #'s to reach you? *
(111) 111-1111 Multiple numbers are OK. Indicate day number please. Fax Number
Email Address/s? * Email where quote will be sent.Email Address Again * Verify Email address to send quote toLast Name? *
First Name? *
Vehicle Make|Model|Year #1 *
2005 Ford Mustang LS give as much information as possible. 4x4, se, dl, le etc. Vehicle Make|Model|Year #2
Leave blank if no other vehicles Your County? * Atlantic County Bergen County Burlington County Camden County Cape May County Cumberland County Essex County Gloucester County Hudson County Hunterdon County Mercer County Middlesex County Monmouth County Morris County Ocean County Passaic County Salem County Somerset County Sussex County Union County Warren County Enter your NJ County of ResidenceTown Name/City? * Enter your NJ City of ResidenceMale or Female? * Male Female NJ PAIP Rates are gender basedDate Of Birth/Age * ex: 01/01/1901 or just 26,40 etcMarital Status * Single Married Divorced Widow/er Distance Driven- miles per day * 1 2 3 4 5 6 7 8 9 10 More than 10 One Way mileage to work or school.Liability Limits needed * 15/30,000 25/50,000 50/100,000 100/300,000 250/500,000 0-NO Liability-BASIC ONLY 10,000 BASIC POLCY ONLY Financed & Leased usually require $100/300Property Damage needed * $5,000 $10,000 $25,000 $50,000 $100,000 5,000 BASIC POLICY ONLY Financed & Leased usually require $50,000PIP Personal Injury Protection needed * $250,000 $150,000 $75,000 $50,000 $15,000 15,000 BASIC POLICY ONLY This covers medical expenses from auto accident etc.Do you have Group Health Insurance? NO YES This could save you money on the PIP PartPIP Personal Injury Protection deductible * $250 $500 $1000 $2,000 $2,500 Your out of pocket deductibleAirbags? * No Airbags Yes 1 Airbag Yes 2 or more Airbags Physical Damage Comprehensive * NO Liability Only Yes $500 deductible Yes $750 deductible Yes $1000 deductible Yes $1500 deductible Yes $2,000 deductible Full Coverage Comprehensive DeductibleCollision Coverage * NO Liability Only Yes $500 deductible Yes $750 deductible Yes $1000 deductible Yes $1500 deductible Yes $2,000 deductible Full Coverage Collision DeductibleStreet Address? * Zip? * Your State? * NJ High Risk Car Insurance Only.Are cars Leased/Financed/Paid Off? * Financed Leased Paid Off Leased/Financed usually require 100/300/50,000 If leased you will need a copy of the lease.Is vehicle Registered to you? * Yes Registered to me No Registerd to someone else Registered to Lease Company Title is OK, Registration Expired Ok,How many licensed drivers in house: TOTAL # * 1 2 3 4 5 6 7 8 9 10 You will need a copy of each NJ DL & Insurance Information.When do you Need Coverage? ASAP This Week Next Week This Month Next Month Later Have you Had a DUI/DWI last 5 years? No Yes DUI-DWI is 9 Insurance PointsAdditional Information Other Drivers-Other Vehicles
Please list other drivers that need to be covered here Age M/F points vehicle driven etc. Your Quote will be emailed. You may need to check bulk Email folder to find your quoteNJ PAIP NJ Car Insurance Quote Form NJ PAIP NJ Car Insurance Quote Form. Your Quote will be emailed directly to you.