Reeves&Melvin Insurance&Real Estate

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To receive an approximation of auto insurance costs, please complete the brief form below. A form must be completed for each driver and car in the household. Please note that this approximation is based on liability limits of $100,000 per occurrence, $300,000 aggregate, and $50,000 property damage limit. A formal quotation will require additional documentation and an "in person" meeting at our Millville, New Jersey office.

Your Name:
House Number
Street
City
Zip
In which county do you live?
Your telephone number:
Your fax number:
Your e-mail address
Your occupation:
Are you married?	Yes No
Your date of birth:
What make of car do you have?
What year is your car? (4 digits)
What model is your car?
What body type is your car?
How long have you held a U.S. license?
Who will be the principle operator(s) of this vehicle?
Their name:
Their relationship to you:
Their date of birth:
Their occupation:
Have you or any other driver had any accidents or claims in the last five years?	Yes No
Have you or any other driver been convicted of any motor offence?	Yes No
What is the primary use of your car?
Respond to me by:

***NOTE*** This is an illustration and not a policy. The policy will have the normal limitations and exclusions applying to all policies issued in this state. The policy will be subject to confirmation of premium rates, driving records and normal underwriting investigation by the company.

Please allow one Week for Quotation.