New Jersey Manufacturers Insurance Company

	Personal Auto Insurance
Most consumers purchase the "Standard" auto insurance policy. However, in New Jersey, customers may select a "Basic Policy," designed to hold down premiums by providing much less coverage. If you are considering "Basic," read this explanation.
	Homeowners or Renters Insurance
	Dwelling Policy
	Personal Umbrella Liability Insurance
	Flood Insurance

* First Name

* Last Name

Designation

* Current Address

* City

* State

* ZIP

* Would the new insurance coverage be effective in NJ or PA?

* Home Telephone

Work Telephone

-- Ext.

* Employer's Name

Employer's Address

Employer's City

Employer's State

Employer's ZIP

Employer's "NJM Number" (if employer is New Jersey Business & Industry Association member)

Current NJM or NJRe Policy Numbers, if any