Classic Car Insurance - Quote Request

Classic Car Insurance Quote Request
What State do you live in?

New JerseyDelawarePennsylvaniaOther
Sorry, we don't write insurance in your State. We only write in NJ, DE, and PA. We are sorry we couldn't help you.
Car Owner Name*

First NameMiddle InitialLast NameSuffix
Owner's address:*

Street Address

Street Address (con't)

CityState

Zip Code
Have you lived here over one year?*

NoYes
Prior Address:

Street Address

Street Address (con't)

CityState

Zip Code
Do you have a different mailing address or PO Box?*

No, same address as aboveYes, I have a different mailing addressOther
Mailing Address

Street Address or PO Box

Street Address Line 2

CityState

Zip Code
Is there a 2nd name on the car Title?*

NoYes
Name of Owner #2:
Date of birth for Owner #2:
ie: 1/15/1990
Home Phone:*
Type "NONE" if you don't have a landline. Enter the cell phone number in the next section.
Cell Phone:
Skip, if you entered you cell phone in prior field
Email address: (if none, pls type "NONE"*
example@example.com
Do you own your home?*

YesNo, I rentNo, I live with parentsNo, but I own and live in a Mobile HomeOther
Does every driver in your household have another car for regular use?*

YesNo
What amount of liability coverage do you have on your Regular Use cars (not the Classic car)?

25,000/50,00050,000/100,000100,000/300,000250,000/500,000Other
Do you have insurance in force for your Classic Car (not for your regular use car), that has been in force for at least 6 months?*

YesNo I don't have insuranceNo, I never had a car before
How long have you been with your current insurance company (for your Classic car) with no lapse?

0 - 6 Months6 - 12 Months1 - 3 Years3 - 5 YearsOver 5 Years
What is the name of your current insurance company (Classic car)?
When will/did your policy expire?
List your Classic Car
Vehicle Type:*
Cart #1: What is the Year, Make, Model?*
ex: 1965 Ford Mustang Convertible 2 door
Cart #1: VIN number Car (you can skip, but this is needed in many cases)
Optional for a quote, but will be required to issue a policy
How many miles do you drive this car per year?*
ie: 2,500
Value of Car:*
ie: 30,000
How long have you owned the car?*
ie: 5 years (or you can type NEW PURCHASE if applicable)
What is the condition of the car?*
Body Type for Car*
License Plate # Car (if you don't have yet please enter TBD*
What State is the car registered in?*
ie: NJ
Is Car #1 kept in a fully enclosed, locked structure?*

NoYes
What type of Garage Structure is the car kept in?*

Fully Enlosed, Locked Private Garage2/3 Wall CarportPrivate Common GarageTrailer (with wheels)Not Garage Kept
Garage Address:*

Same as my home addressOther (Please describe at the end in remarks section)
Who is the primary driver?*
Is Cart #1 either Financed or Leased?*

NeitherMy car is FinancedMy car is Leased
Optional: Name of your lienholder or lessor (address if available)
This is not required to get a quote from us.
Do you want FULL COVERAGE on Car #1?*

No, Liability only pleaseYes, I want full coverage with Comprehensive and Collision
Please select the ways in which you operate the collector car. You may select more than one option:*

Car Shows and Hobby-related ActivitiesVisiting Family/FriendsExercise the Motor/MaintenanceTimed or Racing EventsOccasional General TransportationDriver's Education Events
Please list any clubs you belong to related to Collector Cars*
List of Drivers
Driver #1*

First NameLast Name
Date of Birth - Driver #1*

MonthDayYear
Date
Gender - Driver #1*

MaleFemale
Marital Status for Driver #1:*

SingleMarriedSeparatedDivorcedWidowOther
Have you completed a Defensive Driving course?*

NoYes
Drivers License Number and State for Driver #1:
Ex: A12345678912345 - NJ
Describe any Moving Violations or Accidents within 3 years for Driver #1:*
If no tickets or accidents within 5 years, please type NONE
Are you active in the military?*

NoYes
Add another Driver? (If you are married, spouse info is needed)*

YesNo
Driver #2

First NameLast Name
Date of Birth - Driver #2

MonthDayYear
Date
Gender - Driver #2

MaleFemale
Marital Status for Driver #2:

SingleMarriedSeparatedDivorcedWidowOther
Drivers License Number and State for Driver #2 (if never licensed, indicate NEVER LICENSED):
Ex: A12345678912345 - NJ
How many years of driving experience has driver #2 had? *
Has driver#2 taken a safety course?*

NoYes
Describe any Moving Violations or Accidents within 5 years for Driver #2:
If no tickets or accidents within 5 years, please type NONE
Add a 3rd Driver?

YesNo
Driver #3

First NameLast Name
Date of Birth - Driver #3

MonthDayYear
Date
Gender - Driver #3

MaleFemale
Marital Status for Driver #3:

SingleMarriedSeparatedDivorcedWidowOther
Drivers License Number and State for Driver #3:
Ex: A12345678912345 - NJ
How many years of driving experience has driver #3 had
Has driver#3 taken a safety course? (within the past two years)

NoYes
Describe any Moving Violations or Accidents within 5 years for Driver #3:
If no tickets or accidents within 5 years, please type NONE
How would you like us to contact you? (check as many as you want)*

Email meCall meIt's okay to text me on my cell phone
Any remarks or comments that you would like to add?
How did you find us?*
Were you referred to us by someone? If so, please let us know who referred you so we can send them a thank you.
Would you like this quote request sent to a specific person in our office?
Use this if you would like to upload a copy of your current golf cart insurance policy (optional)

Cancelof
Should be Empty:

Classic Car Insurance Quote Request

List your Classic Car

List of Drivers