Salem County Insurance Agency - Henry D. Young Insurance

For All of Your Insurance Needs

For most people, a house is their most valuable asset and as home and auto insurance rates climb nearly as fast as the price of oil, more and more people are trying to find ways to save money on both their home and car insurance. We will show you how to get the most protection for your home and automobile at the best possible rates.

—Henry D. Young, Inc. Insurance Agency

Auto Insurance

If you own a car, auto insurance is not just an option—it is a legal necessity. And you wouldn’t want it any other way. If you are involved in an accident or have your car stolen, owning the right kind of auto insurance can help to ease a difficult situation. Learn some auto insurance basics and to get the answers to your common questions and then give us a call so we can help you find the most appropriate solutions for your needs. Get a comparative auto quote from a few of our automobile and collector car companies.

Auto Insurance

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For the most accurate quote, please have your vehicle information including vehicle identification numbers for all vehicles and driver information for all drivers including name, date of birth, driver’s license numbers, tickets and accidents available before completing this form. If you don’t have the information, please complete the form using the information you have available.

Client Information:

Your Name *

Spouse or Other Insured’s Name (optional)

Mailing Address*

Street Address *

Apartment, suite, etc

City *

State/Province *

ZIP / Postal Code *

Country

Location Address if different from Mailing Address (optional)

Street Address

Apartment, suite, etc

City

State/Province

ZIP / Postal Code

United States

Home phone number *

Select this if you don’t have home phone numberI dont have phone number

Cell phone number *

Select this if you dont have cell phone numberI don’t have cell phone number

Email Address *

Select this if you don’t have email addressI dont have email address

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Do you own your own home? *YesNo

Prior Address if under 3 years at this address*

Street Address *

Apartment, suite, etc

City *

State/Province *

ZIP / Postal Code *

Country

Prior Address if under 3 years at this addressN/A

Vehicle Information:

How many vehicles to be insured? *

Select No. of vehicles to be insured *1 – Vehicle2 – Vehicles3 – Vehicles4 – VehiclesMore than 4 Vehicles

Please fill upto 4 vehicles information. For remaining vehicles information we will call you.

Vehicle #1 Information

Vehicle #1 Year *

Make *

Model *

Vehicle identification number

Coverage wanted *Liability OnlyFull Coverage (Liablity plus coverage on the vehicle)Don’t Know

Name of the owner of the car *

Name of the owner of the carSame

Select Distance to work one way or Pleasure Use *

Distance to work one way

Pleasure Use

Odometer reading (optional)

Any Business Use? (sales, visit clients, etc.) *YesNo

Any Uber, Lyft, or other transport for hire? *YesNo

Any pizza or other deliveries? *YesNo

Is the car financed or leased? *YesNo

Driver Information – Vehicle #1:

Name of primary driver *

Date of Birth or Age *Date of BirthAgeDon’t Know

Date of Birth

Age

Marital Status (single, married, separated, divorced, widowed, domestic partner) *SingleMarriedSeparatedDivorcedWidowedDomestic partner

Relation to you (spouse, parent, child, other) *SpouseParentChildOther

Driver’s license number (if available)

Tickets or accidents within 5 years? *YesNoDon’t know

If yes, please describe

Has driver been licensed at least 3 years? *YesNoDon’t Know

Vehicle #2 Information

Vehicle #2 Year *

Make *

Model *

Vehicle identification number

Coverage wanted *Liability OnlyFull Coverage (Liablity plus coverage on the vehicle)Don’t Know

Name of the car owner *

Name of the owner of the carSame

Select Distance to work one way or Pleasure Use *

Distance to work one way

Pleasure Use

Odometer reading (optional)

Any Business Use? (sales, visit clients, etc.) *YesNo

Any Uber, Lyft, or other transport for hire? *YesNo

Any pizza or other deliveries? *YesNo

Is the car financed or leased? *YesNo

Driver Information – Vehicle #2:

Name of primary driver *

Date of Birth or Age *Date of BirthAgeDon’t Know

Date of Birth

Age

Marital Status (single, married, separated, divorced, widowed, domestic partner) *SingleMarriedSeparatedDivorcedWidowedDomestic partner

Relation to you (spouse, parent, child, other) *SpouseParentChildOther

Driver’s license number (if available)

Tickets or accidents within 5 years? *YesNoDon’t know

If yes, please describe

Has driver been licensed at least 3 years? *YesNoDon’t Know

Vehicle #3 Information

Vehicle #3 Year *

Make *

Model *

Vehicle identification number

Coverage wanted *Liability OnlyFull Coverage (Liablity plus coverage on the vehicle)Don’t Know

Name of the car owner *

Name of the owner of the carSame

Select Distance to work one way or Pleasure Use *

Distance to work one way

Pleasure Use

Odometer reading (optional)

Any Business Use? (sales, visit clients, etc.) *YesNo

Any Uber, Lyft, or other transport for hire? *YesNo

Any pizza or other deliveries? *YesNo

Is the car financed or leased? *YesNo

Driver Information – Vehicle #3:

Name of primary driver *

Date of Birth or Age *Date of BirthAgeDon’t Know

Date of Birth

Age

Marital Status (single, married, separated, divorced, widowed, domestic partner) *SingleMarriedSeparatedDivorcedWidowedDomestic partner

Relation to you (spouse, parent, child, other) *SpouseParentChildOther

Driver’s license number (if available)

Tickets or accidents within 5 years? *YesNoDon’t know

If yes, please describe

Has driver been licensed at least 3 years? *YesNoDon’t Know

Vehicle #4 Information

Vehicle #4 Year *

Make *

Model *

Vehicle identification number

Coverage wanted *Liability OnlyFull Coverage (Liablity plus coverage on the vehicle)Don’t Know

Name of the car owner *

Name of the owner of the carSame

Select Distance to work one way or Pleasure Use *

Distance to work one way

Pleasure Use

Odometer reading (optional)

Any Business Use? (sales, visit clients, etc.) *YesNo

Any Uber, Lyft, or other transport for hire? *YesNo

Any pizza or other deliveries? *YesNo

Is the car financed or leased? *YesNo

Driver Information – Vehicle #4:

Name of primary driver *

Date of Birth or Age *Date of BirthAgeDon’t Know

Date of Birth

Age

Marital Status (single, married, separated, divorced, widowed, domestic partner) *SingleMarriedSeparatedDivorcedWidowedDomestic partner

Relation to you (spouse, parent, child, other) *SpouseParentChildOther

Driver’s license number (if available)

Tickets or accidents within 5 years? *YesNoDon’t know

If yes, please describe

Has driver been licensed at least 3 years? *YesNoDon’t Know

Prior Insurance

Any insurance in force now? *YesNo

If so, what insurance company

If so, what insurance companyDon’t know

How many years with this company without a lapse in coverage? *Less than 6 monthsLess than 1 year1-3 years4 or more yearsDon’t know

Amount of liability coverage you have on current policy *$15,000/$30,000$25,000/$50,000$50,000/$100,000$100,000/$300,000$250,000/$500,000Don’t knowNo current policyOther

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How did you hear about our agency? *

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