I need help with *
NJPAIP-NJ Car Insurance Standard
Non NJPAIP Standard Policy
NJ PAIP Rates are set by the State Dept of Insurance. You wont have to shop around.
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
MVC/DMV and or Insurance points added together last 36 months.
Were you denied or declined coverage?
NO
YES
NA
Have you been declined for insurance in the last 60 days?
Is Your License SUSPENDED?
NO
YES
Getting Restored
If Suspended You will need A Licensed Driver listed until restored.
Are you trying to replace a current NJPAIP Policy?*
NO
Yes
NA
Many insureds are replacing policies issued prior to 01/01/2009
Phone #'s to reach you? *
(111) 123-4567 Multiple numbers are OK. Indicate day number please.
Fax Number
Email Address/s? *
Email Address Again *
Last Name? *
First Name? *
Year #1|Vehicle Make|Model| *
2009 Dodge Charger EX give as much information as possible. 4x4, se, dl, le etc.
Year #2|Vehicle Make|Model|
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
Select your NJ County of Residence
Town Name/City? *
Male or Female? *
Male
Female
NJ PAIP & NJ Car Insurance Rate Quotes are gender based
Date Of Birth/Age *
Marital Status *
Single
Married
Divorced
Widow/er
Distance Driven- miles per day *
1
2
3
4
5
6
7
8
9
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 $100/300
Property Damage needed *
$5,000
$10,000
$25,000
$50,000
$100,000
5,000 BASIC POLICY ONLY
Financed & Leased usually require $50,000
PIP 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 Part
PIP Personal Injury Protection deductible *
$250
$500
$1000
$2,000
$2,500
Your out of pocket deductible
Airbags? *
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 Deductible
Collision Coverage *
NO Liability Only
Yes $500 deductible
Yes $750 deductible
Yes $1000 deductible
Yes $1500 deductible
Yes $2,000 deductible
Full Coverage Collision Deductible
Street Address? *
Zip? *
Your State? *
NJ
Only available for New Jersey Residents
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
NJ State Law requires disclosure of all licensed operators.
When do you Need Coverage to start?
ASAP
This Week
Next Week
This Month
Next Month
Later
Have you Had a DUI/DWI last 3 years?
No
Yes
DUI-DWI - 9 Insurance Points
Additional Information Other Drivers-Other Vehicles
Please list other drivers that need to be covered here Name Age M/F points vehicle driven etc.
Your Quote will be emailed.
NJ PAIP NJ Car Insurance Quote Form
