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Southern Jersey Contractors Insurance

(908) 730-6443

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Appliance Repairman

Ceiling Installer

Concrete Contractor

Door and Window

Driveway and Paving

Drywall Contractor

Excavation Contractor

Fence Contractor

Floor and Carpet

General Contractor

Handyman Contractor

Household Furnishing

HVAC Contractor

Interior Decorator

Janitorial Contractor

Paving Contractor

Plaster Installer

Roofing Contractor

Siding Installer

Sprinkler Installer

Well Pump Installer

General Liability

Property Insurance

Workers Comp

Other

Company Information

Contact Name
Company
Email
Phone	- -
Fax	- -

Address
Address 2
City
County
Zip

Underwriting Information

Currently Insured?	Yes No
Name of Carrier?
How Long Insured?

Type of Business
(Please be specific, and tell how vehicles are used.)

Driver Information

Driver 1 (if more than two drivers, list in remarks)

Driver Name
Gender	Yes No
Number/Type Accidents Last 3yrs
Number/Type Minor Cites Last 3yrs
Does Driver Need SR22 FILING?	Yes No

Date of Birth
Number of Years U.S. Auto License
Number/Type Major Cites Last 3yrs
Daily Commute (ONE WAY Miles)
Comments

Driver 2 (if none, leave blank)

Driver Name
Gender	Yes No
Number/Type Accidents Last 3yrs
Number/Type Minor Cites Last 3yrs
Does Driver Need SR22 FILING?	Yes No

Date of Birth
Number of Years U.S. Auto License
Number/Type Major Cites Last 3yrs
Daily Commute (ONE WAY Miles)
Comments

Commercial Vehicle Information

Vehicle 1 (if more than two vehicles, list in remarks or call us at 908-730-6443)

Year of Vehicle:
Type (truck, tow-truck, bobtail, etc.)
Gross Vehicle Weight
Radius of Operation
Vehicle ID# (for accurate rating)

Make & Model:
Length in Feet
Cost New
Current Value

List Special Equipment & Values

Vehicle 1 Coverages

Limits of Liability	$500,000 CSL $750,000 CSL $1 Million CSL
Do you want Medical Coverage?	Yes No

Comprehensive & Collision	NO Coverage $250 Deductible $500 Deductible $1,000 Deductible
Uninsured Motorists?	Yes No

Vehicle 2 (if more than two vehicles, list in remarks or call us at 908-730-6443)

Year of Vehicle:
Type (truck, tow-truck, bobtail, etc.)
Gross Vehicle Weight
Radius of Operation
Vehicle ID# (for accurate rating)

Make & Model:
Length in Feet
Cost New
Current Value

List Special Equipment & Values

Vehicle 2 Coverages

Limits of Liability	$500,000 CSL $750,000 CSL $1 Million CSL
Do you want Medical Coverage?	Yes No

Comprehensive & Collision	NO Coverage $250 Deductible $500 Deductible $1,000 Deductible
Uninsured Motorists?	Yes No

Comments/Remarks


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Southern Jersey Contractors Insurance offered for virtually all NJ contractors
Atlantic County NJ	Deptford NJ	Magnolia NJ	Somers Point NJ
Camden County NJ	Downe NJ	Mannington NJ	South Harrison NJ
Cape May County NJ	East Greenwich NJ	Mantua NJ	Stone Harbor NJ
Cumberland County NJ	Egg Harbor NJ	Margate City NJ	Stow Creek NJ
Gloucester County NJ	Egg Harbor City NJ	Maurice River NJ	Stratford NJ
Salem County NJ	Elk NJ	Merchantville NJ	Swedesboro NJ
Southern Jersey NJ	Elmer NJ	Middle NJ	Tavistock NJ
	Elsinboro NJ	Millville NJ	Upper NJ
Absecon NJ	Estell Manor NJ	Monroe NJ	Upper Deerfield NJ
Alloway NJ	Fairfield NJ	Mount Ephraim NJ	Upper Pittsgrove NJ
Atlantic City NJ	Folsom NJ	Mullica NJ	Ventnor City NJ
Audubon NJ	Franklin NJ	National Park NJ	Vineland NJ
Audubon Park NJ	Galloway NJ	Newfield NJ	Voorhees NJ
Avalon NJ	Gibbsboro NJ	North Wildwood NJ	Washington NJ
Barrington NJ	Glassboro NJ	Northfield NJ	Waterford NJ
Bellmawr NJ	Gloucester NJ	Oaklyn NJ	Wenonah NJ
Berlin NJ	Gloucester City NJ	Ocean City NJ	West Cape May NJ
Bridgeton NJ	Greenwich NJ	Oldmans NJ	West Deptford NJ
Brigantine NJ	Haddon NJ	Paulsboro NJ	West Wildwood NJ
Brooklawn NJ	Haddon Heights NJ	Penns Grove NJ	Westville NJ
Buena NJ	Haddonfield NJ	Pennsauken NJ	Weymouth NJ
Buena Vista NJ	Hamilton NJ	Pennsville NJ	Wildwood NJ
Camden NJ	Hammonton NJ	Pilesgrove NJ	Wildwood Crest NJ
Cape May NJ	Harrison NJ	Pine Hill NJ	Winslow NJ
Cape May Point NJ	Hi-Nella NJ	Pine Valley NJ	Woodbine NJ
Carneys Point NJ	Hopewell NJ	Pitman NJ	Woodbury NJ
Cherry Hill NJ	Laurel Springs NJ	Pittsgrove NJ	Woodbury Heights NJ
Chesilhurst NJ	Lawnside NJ	Pleasantville NJ	Woodlynne NJ
Clayton NJ	Lawrence NJ	Port Republic NJ	Woodstown NJ
Clementon NJ	Lindenwold NJ	Quinton NJ	Woolwich NJ
Collingswood NJ	Linwood NJ	Runnemede NJ
Commercial NJ	Logan NJ	Salem NJ
Corbin City NJ	Longport NJ	Sea Isle City NJ
Deerfield NJ	Lower NJ	Shiloh NJ
Dennis NJ	Lower Alloways Creek NJ	Somerdale NJ

Friedlander Associates | 56 Payne Road Suite 2 Lebanon, NJ 08833 | (908) 730-6443 Phone | (908) 735-0203 Fax

Commercial Auto Insurance Southern Jersey

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