Sens-O-Lock | NJ Cheap Interlock Order Form

First Name & Middle Initial*

Last Name*

Street Address*

City*

State*

Zip*

County*

Date of Birth*

Gender*

Driver License #*

Email*

Phone*

Voluntary/Mandatory*

Term*

Vehicle Make*

Vehicle Model*

Vehicle Year*

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Credit Card Type*

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Credit Card Number*

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Card Holder Name*

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Expiration Month*

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Expiration Year*

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CCV*

LOSS PROTECTION PLAN: In the event the Equipment is lost, stolen or damaged in an accident, the Lessee shall pay the sum of $1,995.00 to replace the equipment or necessary repair fees and shall continue to make the monthly payments due hereunder. Lessee may obtain loss protection under the Loss Protection Plan for an additional monthly cost of $7.00. This loss protection will cover the system/device replacement cost less a $100.00 deductible fee. A police report must be filed and submitted to Lessor if the system is stolen or damaged resulting from an accident.*

Yes, I accept the Loss Protection Plan at monthly premium of $7.00.
No, I decline the Loss Protection Plan (at monthly premium of $7.00) and acknowledge my responsibility for any loss or damage to the Equipment, with complete loss valued at $1,995.00.