CLASSIC AUTO INSURANCE QUOTATION APPLICATION

At Coe Insurance can provide superior coverage for your collector vehicle, but at a price much lower than your regular auto insurance carrier can offer. We know that you want to keep your vehicle in great shape; and we reward you with a great rate.

Because we understand the unique value ascribed to collectible autos, we provide Agreed Value Coverage. Which means that you and Coe Insurance establish the value of your particular vehicle based on current market, history, quality and restoration and overall condition. We have high limits of liability available including coverage for uninsured motorist and medical expenses, to best protect your classic auto.

    Am I Eligible?
  • Is your vehicle in restored, or good original condition?
  • Is your vehicle stored in a fully enclosed garage?
  • Do you intend to use the vehicle primarily for show, parades and other hobby related activities?
  • Do you have a reasonably clean driving record?
  • Do you have other modern vehicles for your family's daily transportation needs?

If you answered "yes" to all the eligible questions, your likely eligible for coverage. If you answered "no" to any of the questions, please feel free to call us at 201-435-4300 to discuss your options with one of our representatives.

Information submitted will be held confidential and will be used for quote purposes only. Submission of application information in no way obligates you to purchase any product or insurance, nor does it represent any agreement to provide coverage under any insurance policy.

Personal Information
First Name: Last Name:
E-Mail:
Phone Numbers:
Daytime:
Evening:
Fax:
Contact Preference: Daytime Evening Fax E-Mail
When is the best time to reach you?:
Address:
City: State: Zip Code:
Do you currently own your home or rent? Own Rent
Driver's License Number:
Social Security Number: (optional)
Drivers Information - Please list all individuals who will drive the Classic Auto
 
Name:
Relationship to applicant:
Sex:
Marital Status:
Driver's Age:
Percent Use:
Driver #1
Male
Female
Married
Single
Driver #2
Male
Female
Married
Single
Driver #3
Male
Female
Married
Single
Driver #4
Male
Female
Married
Single
Drivers History
Who is the Primary Insurance Carrier?:
Please answer the below 4 questions about you or any other driver in your household:
Had a ticket in the last 3 years? Yes No
Had a license suspended or revoked in the last 6 years? Yes No
Had a financial responsibility filing in the last 6 years? Yes No
Made any claims in the last 5 years? Yes No
If you answered yes to any of the above questions, please explain:
Classic Auto Information
Year: Make: Model: VIN:
Primary Driver: Annual Mileage: Appox. Value:
Is the vehicle driven to school or work? Yes No
If driven to school or work, how many weeks per month? Days: Weeks:
If driven to school or work, how many miles one way? Miles:
Is the vehicle in any way modified or customized? Yes No
Is there any existing damage to the vehicle? Yes No
If the vehicle is kept at an address other than that listed above, please indicate below:
Address:
City: State: Zip Code:
Coverage Options
Bodily injury liability:
Property damage liability:
Underinsured motorist-bodily injury:
Underinsured motorist-property damage:
Medical-Personal injury protection:
Do you want your health carrier to be the primary payer of health expenses?:
Coverage Deductibles
  Comprehensive Deductible Collision Deductible
Classic Auto #1:
Questions, Comments or Additional Automobile Information?