Joseph H. McGlone, Inc.
Insurance Analyst
Joseph H. McGlone respects your privacy and will not share any information with another party without your consent.
For your ONLINE AUTO QUOTE in
NJ and PA
please fill out and submit the following form:
Please fill out this form as complete as possible. If you are not sure of a response, leave it blank and we will contact you and help you obtain the information necessary for your quote.
Customer Information
 
Please choose:
 
 
 
Last name:
 
 
First name:
 
 
 
Address:
City, State, Zip:
E-mail address:
 
 
 
Home phone:
 
 
Work phone:
 
 
 
Vehicle #1 Information
 
Make of car
 
 
Model
 
 
Year
 
 
 
Vehicle Identification Number
 
 
 
Body style
 
 
Doors
 
 
Cylinders
 
 
 
 
Passenger protection
 
 
Antitheft Device
 
 
 
 
 
Vehicle is owned
 
 
or vehicle is leased
 
 
Total annual miles
 
 
 
Vehicle used for:
 
pleasure
business
 
 
what type of business
 
 
 
commuting
 
 
(to work, school, or mass transit center)
 
If used for commuting where to? (street, city, state, zip)
 
Vehicle is used
 
 
days per week to commute
 
 
miles (one way)
 
 
Vehicle #2 Information
 
Make of car
 
 
Model
 
 
Year
 
 
 
Vehicle Identification Number
 
 
 
Body style
 
 
Doors
 
 
Cylinders
 
 
 
 
Passenger protection
 
 
Antitheft Device
 
 
 
 
 
Vehicle is owned
 
 
or vehicle is leased
 
 
Total annual miles
 
 
 
Vehicle used for:
 
pleasure
business
 
 
what type of business
 
 
 
commuting
 
 
(to work, school, or mass transit center)
 
If used for commuting where to? (street, city, state, zip)
 
Vehicle is used
 
 
days per week to commute
 
 
miles (one way)
 
 
Vehicle #3 Information
 
Make of car
 
 
Model
 
 
Year
 
 
 
Vehicle Identification Number
 
 
 
Body style
 
 
Doors
 
 
Cylinders
 
 
 
 
Passenger protection
 
 
Antitheft Device
 
 
 
 
 
Vehicle is owned
 
 
or vehicle is leased
 
 
Total annual miles
 
 
 
Vehicle used for:
 
pleasure
business
 
 
what type of business
 
 
 
commuting
 
 
(to work, school, or mass transit center)
 
If used for commuting where to? (street, city, state, zip)
 
Vehicle is used
 
 
days per week to commute
 
 
miles (one way)
 
 
Vehicle #2 Information
 
Make of car
 
 
Model
 
 
Year
 
 
 
Vehicle Identification Number
 
 
 
Body style
 
 
Doors
 
 
Cylinders
 
 
 
 
Passenger protection
 
 
Antitheft Device
 
 
 
 
 
Vehicle is owned
 
 
or vehicle is leased
 
 
Total annual miles
 
 
 
Vehicle used for:
 
pleasure
business
 
 
what type of business
 
 
 
commuting
 
 
(to work, school, or mass transit center)
 
If used for commuting where to? (street, city, state, zip)
 
Vehicle is used
 
 
days per week to commute
 
 
miles (one way)
 
 
Driver Information
Provide information for ALL licensed residents living in your household.
Driver 1 Driver 2 Driver 3 Driver 4
Name
Relationship to # 1
Occupation
Sex
Date of birth
Marital status
** Drivers license #
**Social security #
Year licensed
Tickets last 3 yrs
Accidents last 3 yrs
Education LEVEL
**this information is optional -(used to determine eligibility for preferred program)
Please list all accidents and violations below. The list should include approximate dates, points, description, and amount paid by your insurance company to you or another party. For example: 10/4/99 speeding ticket 13 miles over the limit for 2 points. or 5/1/00 I rear ended another party and my company paid them $1300.
 
Current Insurance Information
 
Present Insurance Company
How long with current carrier
 
 
 
Expiration date
 
 
OR Cancellation date
 
 
 
Is this policy currently in force
 
yes
 
 
no
 
 
 
Coverage Requested
 
Collision Deductible
 
 
Comprehensive Deductible
 
 
 
Split Liability Limits
OR
 
 
or other
 
 
 
Combined Single Liability Limit
 
 
or other