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Privacy Policy-We routinely collect personal and/or business information that is needed as part of the quoting and underwriting process.  We also collect the same information as part of service and update activities.  The Haines & Haines/T.C. Irons Agency will not share that information, or use it in any other way, with outside parties, vendors, etc.

Personal Auto Insurance Quotation

 

GENERAL INFORMATION

Street Address
City
State
Zip Code
Marital Status
Single Married 		Homeowner?
Yes No
 
Currently Insured?
Yes No
Current or prior insurance company:

If Not Currently Insured
When did Coverage End?
How long have you been
CONTINUOUSLY Insured?

Current Policy Term

Current Policy Expiration Date
Current Policy Premium
 
Current Limits of
Liability		 $25k/50k $50k/100k
$100k/300k $250k/500k


DRIVER #1 INFORMATION
Name Birth date
Sex (M/F) # Years U.S.
 Licensing
Occupation (If self-employed, please enter job description)
Highest Education


In order to obtain all available DISCOUNTS, carriers run a low level insurance credit check. By providing Social Security # and Driver's License #, we can obtain the LOWEST RATE AVAILABLE!
Driver 1 Social
Security #		 Driver 1 Driver's
License #
State or Country
of License

- IMPORTANT INFORMATION -
 To receive an accurate quote, you must provide information regarding the
approx. DATE and TYPE of any CLAIMS or TRAFFIC VIOLATIONS
within the last 39 MONTHS.
DATE CLAIM / TRAFFIC VIOLATION TYPE







Have You Attended a Defensive Driving Course within last 3 years? (Check if yes)

DRIVER #2 INFORMATION
Name Birth Date
Sex (M/F) # Years U.S.
 Licensing
Occupation (If self-employed, please enter job description)
Highest Education


In order to obtain all available DISCOUNTS, carriers run a low level insurance credit check. By providing Social Security # and Driver's License #, we can obtain the LOWEST RATE AVAILABLE!
Driver 2 Social
Security #		 Driver 2 Driver's
License #
State or Country
of License

- IMPORTANT INFORMATION -
 To receive an accurate quote, you must provide information regarding the
approx. DATE and TYPE of any CLAIMS or TRAFFIC VIOLATIONS
within the last 39 MONTHS.
DATE CLAIM / TRAFFIC VIOLATION TYPE







Defensive Driving Course within last 3 years Check if yes

VEHICLE #1 INFORMATION
(if "Non-Owners", type "NON-OWNER" in "YEAR" Field)
Year of Vehicle Make
Model:
Sub Model: (EX,LX, etc.)
4 Wheel Drive? Y   N
Convertible? Y   N
# of Doors
Est Annual Mileage Usage
Business Use Detail
Miles to Work
Features-
Check all apply		 ABS Alarm System 1 Air Bag
Lojack Vin Etching 2 Air Bags
Daytime Lights      Auto Seat Belts
Vehicle ID/VIN
VEHICLE #1 COVERAGE
MANDATORY COVERAGE  Please Select One Option:
($25k / 50k - $10k is the minimum allowed by law)
BI/GP - PD
(See Definitions)		 $25k / 50k - $10k     $50k / 100k - $25k
$100k / 300k - $50k $250k / 500k - $100k
For  FULL COVERAGE  Please Select a Deductible Below
Comprehensive
& Collision		 NO Coverage $250 Deductible
$500 Deductible $1000 Deductible

VEHICLE #2 INFORMATION
Year of Vehicle Make
Model
Sub Model (EX,LX, etc.)
4 Wheel Drive? Y   N
Convertible? Y   N
# of Doors?
Est Annual Mileage Usage
Business Use Detail
Miles to Work
Features-
Check all apply		 ABS Alarm System 1 Air Bag
Lojack Vin Etching 2 Air Bags
Daytime Lights      Auto Seat Belts
Vehicle ID/VIN
VEHICLE #2 COVERAGES:
Comprehensive
& Collision		 NO Coverage $250 Deductible
$500 Deductible $1000 Deductible

 CONTACT INFORMATION
First Name

Last Name

Email

Phone                        Fax
  
Questions / Comments / Notes
Send my quotation via E-Mail Fax
Regular Mail
Call me by Phone!

All quotes are based on the information that the applicant  provides, and are subject to change based on final underwriting by the  individual carriers.


Our Mission Statement
Dating back from 1872 our mission is clear:
To serve our clients with the utmost respect, integrity and professionalism while providing a comprehensive risk management program at competitive pricing
 


Get a Quote

Contactenos ahora, hablamos su idioma.

 

 

Policy Coverage
and Disclaimer


  Haines & Haines/ T.C. Irons  
16 West Front Street
Florence, NJ 08518
Phone: 609.499.0237 
Fax: 609.499.4077		 230 High Street PO Box 158- Burlington, NJ 08016
Phone: 609.387.0606
Fax: 609.387.5337
 1-3 Bank Street
Suite E
Medford, NJ 08055
Phone: 609-953-2282 
Fax: 609.953.7719
  Wesley Insurance Service Agency
1194 Parkway Avenue Trenton, NJ 08628
Phone: 609.883.4190
Fax: 609.538.0274