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Plymouth Rock offers car insurance discounts to members of several organizations including Atlantic City Chamber, Vineland Chamber of Commerce, NJ Association of Realtors. Be sure to indicate within your quote if you are a member of one of their designated organizations.


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Contact Information:

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Address
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Current Insurance Information:

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Vehicle Information:

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Alarm
Any custom equipment on vehicle?

Coverage Information:

Deductible Vehicle:

Towing Coverage
Rental Reimb.

Driver Information:

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(mm/dd/yyyy)
Sex
Marital Status
Driver's Education?
Defensive Driving?
Good Student?
SR 22 Filing?

Accidents / Violations in the last 5 years for Driver:

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Additional Comments:

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