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What forms are needed in the state of New Jersey?

The available forms and a brief description are listed below. You can open a .pdf version of these forms by clicking on the desired form number in the 'File Attachments' section below.

The form you print and complete is determined by the type of policy you have purchased and the insurance company issuing the policy. The first selection is whether you have purchased a Standard policy or a Basic policy. The Standard policy has multiple coverage options. The Basic policy has limited coverage and limit options. The large majority of consumers purchase a Standard policy.

The next determination is the 21st Century Insurance affiliated insurance company through which your policy is issued in New Jersey. There are forms below for 21st Century Pinnacle Insurance Company, 21st Century Assurance Company, or 21st Century Centennial Insurance Company. The company name can be found listed on your policy declarations page or on your quote. Choose the specific form for the company indicated on these documents.

You must complete, sign and return the appropriate form listed below. It should be reviewed in conjunction with the New Jersey Buyer's Guide.

New Jersey Auto Insurance Buyer's Guide: BG-NJ (1/14) - Refer to this document for an explanation of New Jersey Auto insurance options and when completing the Coverage Selection Form.

New Jersey Auto Insurance Consumer Bill of Rights: NJ-BOR (1/10) - This document provides you with information about certain consumer rights that pertain to your auto insurance coverage.

21st Century Pinnacle Insurance Company

Standard Policy Coverage Selection Form: AU NJ39a 0613 - If you have not previously completed and signed a Coverage Selection Form or if you want to make changes to your current coverage, please print and complete this form.

Basic Policy Coverage Selection Form: AU NJ39c 0613 - If you have not previously completed and signed a Coverage Selection Form or if you want to make changes to your current coverage, please print and complete this form.

21st Century Assurance Company

Standard Policy Coverage Selection Form: AU NJ39b 0214 - If you have not previously completed and signed a Coverage Selection Form or if you want to make changes to your current coverage, please print and complete this form.

Basic Policy Coverage Selection Form: AU NJ39d 0214 - If you have not previously completed and signed a Coverage Selection Form or if you want to make changes to your current coverage, please print and complete this form.

21st Century Centennial Insurance Company

Standard Policy Coverage Selection Form: AU NJ39e 0214 - If you have not previously completed and signed a Coverage Selection Form or if you want to make changes to your current coverage, please print and complete this form.

Basic Policy Coverage Selection Form: AU NJ39f 0214 - If you have not previously completed and signed a Coverage Selection Form or if you want to make changes to your current coverage, please print and complete this form.

Once you have completed the appropriate Coverage Selection Form, please send the form to the address below.

Physical Mailing and Overnight Address:

Overnight - Correspondence
21st Century Insurance
3 Beaver Valley Rd - 4th Floor
Wilmington, DE 19803

Fax Number: 1(866) 447-2611

File Attachments

New Jersey Auto Insurance Buyer's Guide (BG-NJ 1/14).pdf
Automobile Insurance Consumer Bill Of Rights (NJ-BOR 1-10).pdf
21st Century Pinnacle Insurance Company - Standard Policy (AU NJ39a 0613).pdf
21st Century Assurance Company - Standard Policy (AU NJ39b 0214).pdf
21st Century Pinnacle Insurance Company - Basic Policy (AU NJ39c 0613).pdf
21st Century Assurance Company - Basic Policy (AU NJ39d 0214).pdf
21st Century Centennial Insurance Company - Standard Policy (AU NJ39e 0214).pdf
21st Century Centennial Insurance Company - Basic Policy (AU NJ39f 0214).pdf

Topics

General Information
Coverage
State Forms
 

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