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 together
last 36 months.
Were you Canceled MID-TERM more than 30 days?
NA
YES
NO
MID Term Cancellations require Non Payment Cancellation Letter
from insurance company.
Is Your License SUSPENDED?
NO
YES
Getting Restored
If Suspended You will need A Licensed Driver listed until
restored.
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 Address Again *
Last 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 Residence
Town Name/City? *
Male or Female? *
Male
Female
NJ PAIP Rates 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
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 $100/300
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
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 Points
Additional 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.
NJ PAIP NJ Car Insurance Quote Form
