Generazio Associates, Inc.

Auto Insurance Quote Form

For the quickest and most accurate insurance quote, please provide as much information as possible in the form below.

THIS INFORMATION WILL BE KEPT CONFIDENTIAL
AND WILL BE USED FOR QUOTING PURPOSES ONLY!

General Information

SAME DAY COVERAGE

Name:

Address:

City:

State:

Zip Code:

SSN:

County:

Date of Birth:

(mm/dd/yyyy)

Phone #:

Cell #:

Work #:

Best Time To Be Reached:

Discount for Home & Auto Package (up to 24 % dis.):
	Yes No (If yes fill out homeowner quote sheet)
Do You Have Insurance Now?	Yes No
If yes how long with current company?

If No, When Was Last Time Insured?

If No, Why Canceled?

Auto Information

Car 1

Car 2

Car 3

Year:

Make:

VIN #: (Required if known)

Full Model:
(ex: LE, DX, LX etc)

Body Type:

Vehicle Use:

If Drive To Work, Miles 1 Way:

Coverages

Liability BI:		Property Damage:
UM/UMBI:		UM/UMIPD:

Basic PiP: Quoting will be done with $250,000 Limit with $250.00 Deductible. If you would like a quote with a different Basic Pip please indicate In the "Other" box.

Car 1

Car 2

Car 3

Comprehensive Deductible:

Collision Deductible:

Driver Information 1

Name:

D.O.B.:

Gender:

Male Female

Veh driven:

Marital Status:

Driver Information 2

Name:

D.O.B.:

Gender:

Male Female

Veh driven:

Marital Status:

Driver Information 3

Name:

D.O.B.:

Gender:

Male Female

Veh driven:

Marital Status:

Driver History:

List dates + payouts
description for all tickets, suspensions,
and accidets in the
past 5 years:

List Good Student: (dd/mm/yyyy)
Driver Training: (dd/mm/yyyy)
Defensive Course: (dd/mm/yyyy)

Additional Information:

Feedback:

Suggestions on how we can
improve our quote sheets

How did you hear about us ?

Generazio Associates, Inc.
265 Broad Street Bloomfield, NJ 070073 Phone: 973-429-8100 Fax: 973-429-9763	515 Washington Road Parlin, NJ 08859 Phone: 732-257-2600 Fax: 9732-257-7921