Collector Car Insurance Expanded Form

What is your first name? **

What is your first name? *

What is your last name? **

What is your last name? *

What is your preferred phone number? **

What is your preferred phone number? *

What is your email address? **

What is your email address? *

What is your occupation?

What is the name of your employer?

What is your date of birth? **

What is your date of birth? *

What is your driver's license number? **

What is your driver's license number? *

What state are you licensed in? **

What state are you licensed in? *

What is your gender?

Male
Female

Do you operate the collector car(s)?

Yes
No

What percentage of time are you operating the collector car(s)?

What percentage of time are you operating the collector car(s)? (Ex. 10%)

What is your marital status? **

What is your marital status? *

What is your spouse's full name?

What is your partner's full name?

What is your fiancé's full name?

What is their gender?

Male
Female

Please enter their occupation.

Please enter their employer.

Please enter their date of birth.

What is their driver's license number? **

What is their driver's license number? *

What state are they licensed in? **

What state are they licensed in? *

Do they operate the collector car(s)?

Yes
No

What percentage of time are they operating the collector car(s)? 2

What percentage of time are they operating the collector car(s)? (Ex. 10%)

Please enter your primary home address.

Street Address Address Line 2 City State ZIP Code

Is this residence owned or rented?

Owned
Rented

Garaging Location

Is this the address where your collector vehicle(s) is/are kept?

Yes
No

Garaging Address

Please enter the address where your vehicle(s) is/are kept.

Street Address Address Line 2 City State ZIP Code

Do you currently have insurance in force?

Yes
No

What is the name of the insurance company?

What date would you like to have this new coverage for your collector car(s) take effect? **

What date would you like to have this new coverage for your collector car(s) take effect? *

How many collector cars are in the collection for which you would like an insurance proposal? (Include vehicles you are in the process of purchasing) **

How many collector cars are in the collection for which you would like an insurance proposal? (Include vehicles you are in the process of purchasing) *

Collector Car #1

Please enter the year, make, model, body type and VIN. **

Please enter the year, make, model, body type and VIN. *

Year, Make, Model, Body Type	Vehicle Identification Number

Please select the category that best suites this vehicle.

Are you in the process of purchasing this collector car? **

Are you in the process of purchasing this collector car? *

Yes
No

What date will you pick up the vehicle? **

What date will you pick up the vehicle? *

What date did you acquire this vehicle? **

What date did you acquire this vehicle? *

Will you be financing this purchase?

Yes
No

Does this vehicle have a lien holder?

Yes
No

What is the name of the lien holder for this vehicle?

What is the address of the lien holder for this vehicle?

Street Address Address Line 2 City State ZIP Code

What is the registration state? **

What is the registration state? *

How many years have you owned this vehicle?

Please rate the condition of this vehicle on a scale of 1 to 100. (100 = Perfection)

What is the value of this vehicle?

Do you have a current appraisal for this vehicle?

Yes
No

Please upload a copy of the appraisal, if convenient.

Drop files here or

Max. file size: 128 MB.

How many miles is this vehicle driven on an annual basis?

What is the current odometer reading?

Is this a high performance vehicle?

Yes
No

Is this vehicle owned by a Business, Trust, LLC, Limited Partnership or other legal entity?

Yes
No

Will you title this vehicle in the name a Business, Trust, LLC, Limited Partnership or other legal entity?

Yes
No

Please provide the name in which this vehicle is titled.

Please provide the name to which this vehicle will be titled.

Enter the name of the primary driver of this vehicle?

Please select the option that best describes how this vehicle will primarily be used.

How many miles does this vehicle commute each way?

Please provide details about the usage of this vehicle.

What type of coverage would you like for this vehicle?

Full coverage
Liability only
Not sure

What deductible option would you like for comprehensive coverage on this vehicle?

What deductible option would you like for collision coverage on this vehicle?

Has any custom work been done to this vehicle?

Yes
No

What is the value of the work that was done to this vehicle?

Please provide a description of the custom work that was done to this vehicle.

Is this vehicle currently being repaired/restored?

Yes
No

What is the expected completion date?

What is the name of the shop where the car is being repaired/restored?

What is the address of the shop where the vehicle is being repaired/restored?

Street Address Address Line 2 City State ZIP Code

Will the original horsepower be increased or modified during this renovation?

Yes
No

Please provide details about the horsepower modification:

Will the engine, suspension, body, or drivetrain be changed during this renovation?

Yes
No

Please provide details about the engine, suspension, body, or drivetrain changes.

Please provide a description of the renovation currently underway.

Please upload up to three pictures of the vehicle here:

Drop files here or

Max. file size: 128 MB, Max. files: 3.

Collector Car #2

Please enter the year, make, model, body type and VIN. * 2*

Please enter the year, make, model, body type and VIN. *

Year, Make, Model, Body Type	Vehicle Identification Number

Please select the category that best suites this vehicle.2

Please select the category that best suites this vehicle.

Are you in the process of purchasing this collector car? *2*

Are you in the process of purchasing this collector car? *

Yes
No

What date will you pick up the vehicle? *2*

What date will you pick up the vehicle? *

What date did you acquire this vehicle? *2*

What date did you acquire this vehicle? *

Will you be financing this purchase?2

Will you be financing this purchase?

Yes
No

Does this vehicle have a lien holder?2

Does this vehicle have a lien holder?

Yes
No

What is the name of the lien holder for this vehicle?2

What is the name of the lien holder for this vehicle?

What is the address of the lien holder for this vehicle?2

What is the address of the lien holder for this vehicle?

Street Address Address Line 2 City State ZIP Code

What is the registration state? *2*

What is the registration state? *

How many years have you owned this vehicle?2

How many years have you owned this vehicle?

Please rate the condition of this vehicle on a scale of 1 to 100. (100 = Perfection)2

Please rate the condition of this vehicle on a scale of 1 to 100. (100 = Perfection)

What is the value of this vehicle?2

What is the value of this vehicle?

Do you have a current appraisal for this vehicle?2

Do you have a current appraisal for this vehicle?

Yes
No

Please upload a copy of the appraisal, if convenient.2

Please upload a copy of the appraisal, if convenient.

Drop files here or

Max. file size: 128 MB.

How many miles is this vehicle driven on an annual basis?2

How many miles is this vehicle driven on an annual basis?

What is the current odometer reading?2

What is the current odometer reading?

Is this a high performance vehicle?2

Is this a high performance vehicle?

Yes
No

Is this vehicle owned by a Business, Trust, LLC, Limited Partnership or other legal entity?2

Is this vehicle owned by a Business, Trust, LLC, Limited Partnership or other legal entity?

Yes
No

Will you title this vehicle in the name a Business, Trust, LLC, Limited Partnership or other legal entity?2

Will you title this vehicle in the name a Business, Trust, LLC, Limited Partnership or other legal entity?

Yes
No

Please provide the name in which this vehicle is titled.2

Please provide the name in which this vehicle is titled.

Please provide the name to which this vehicle will be titled.2

Please provide the name to which this vehicle will be titled.

Enter the name of the primary driver of this vehicle?2

Enter the name of the primary driver of this vehicle?

Please select the option that best describes how this vehicle will primarily be used.2

Please select the option that best describes how this vehicle will primarily be used.

How many miles does this vehicle commute each way?2

How many miles does this vehicle commute each way?

Please provide details about the usage of this vehicle.2

Please provide details about the usage of this vehicle.

What type of coverage would you like for this vehicle?2

What type of coverage would you like for this vehicle?

Full coverage
Liability only
Not sure

What deductible option would you like for comprehensive coverage on this vehicle?2

What deductible option would you like for comprehensive coverage on this vehicle?

What deductible option would you like for collision coverage on this vehicle?2

What deductible option would you like for collision coverage on this vehicle?

Has any custom work been done to this vehicle?2

Has any custom work been done to this vehicle?

Yes
No

What is the value of the work that was done to this vehicle?2

What is the value of the work that was done to this vehicle?

Please provide a description of the custom work that was done to this vehicle.2

Please provide a description of the custom work that was done to this vehicle.

Is this vehicle currently being repaired/restored?2

Is this vehicle currently being repaired/restored?

Yes
No

What is the expected completion date?2

What is the expected completion date?

What is the name of the shop where the car is being repaired/restored?2

What is the name of the shop where the car is being repaired/restored?

What is the address of the shop where the vehicle is being repaired/restored?2

What is the address of the shop where the vehicle is being repaired/restored?

Street Address Address Line 2 City State ZIP Code

Will the original horsepower be increased or modified during this renovation?2

Will the original horsepower be increased or modified during this renovation?

Yes
No

Please provide details about the horsepower modification:2

Please provide details about the horsepower modification:

Will the engine, suspension, body, or drivetrain be changed during this renovation?2

Will the engine, suspension, body, or drivetrain be changed during this renovation?

Yes
No

Please provide details about the engine, suspension, body, or drivetrain changes.2

Please provide details about the engine, suspension, body, or drivetrain changes.

Please provide a description of the renovation currently underway.2

Please provide a description of the renovation currently underway.

Please upload up to three pictures of the vehicle here:2

Please upload up to three pictures of the vehicle here:

Drop files here or

Max. file size: 128 MB, Max. files: 3.

Collector Car #3

Please enter the year, make, model, body type and VIN. *3*

Please enter the year, make, model, body type and VIN. *

Year, Make, Model, Body Type	Vehicle Identification Number

Please select the category that best suites this vehicle.3

Please select the category that best suites this vehicle.

Are you in the process of purchasing this collector car? *3*

Are you in the process of purchasing this collector car? *

Yes
No

What date will you pick up the vehicle? *3*

What date will you pick up the vehicle? *

What date did you acquire this vehicle? *3*

What date did you acquire this vehicle? *

Will you be financing this purchase?3

Will you be financing this purchase?

Yes
No

Does this vehicle have a lien holder?3

Does this vehicle have a lien holder?

Yes
No

What is the name of the lien holder for this vehicle?3

What is the name of the lien holder for this vehicle?

What is the address of the lien holder for this vehicle?3

What is the address of the lien holder for this vehicle?

Street Address Address Line 2 City State ZIP Code

What is the registration state? *3*

What is the registration state? *

How many years have you owned this vehicle?3

How many years have you owned this vehicle?

Please rate the condition of this vehicle on a scale of 1 to 100. (100 = Perfection)3

Please rate the condition of this vehicle on a scale of 1 to 100. (100 = Perfection)

What is the value of this vehicle?3

What is the value of this vehicle?

Do you have a current appraisal for this vehicle?3

Do you have a current appraisal for this vehicle?

Yes
No

Please upload a copy of the appraisal, if convenient.3

Please upload a copy of the appraisal, if convenient.

Drop files here or

Max. file size: 128 MB.

How many miles is this vehicle driven on an annual basis?3

How many miles is this vehicle driven on an annual basis?

What is the current odometer reading?3

What is the current odometer reading?

Is this a high performance vehicle?3

Is this a high performance vehicle?

Yes
No

Is this vehicle owned by a Business, Trust, LLC, Limited Partnership or other legal entity?3

Is this vehicle owned by a Business, Trust, LLC, Limited Partnership or other legal entity?

Yes
No

Will you title this vehicle in the name a Business, Trust, LLC, Limited Partnership or other legal entity?3

Will you title this vehicle in the name a Business, Trust, LLC, Limited Partnership or other legal entity?

Yes
No

Please provide the name in which this vehicle is titled.3

Please provide the name in which this vehicle is titled.

Please provide the name to which this vehicle will be titled.3

Please provide the name to which this vehicle will be titled.

Enter the name of the primary driver of this vehicle?3

Enter the name of the primary driver of this vehicle?

Please select the option that best describes how this vehicle will primarily be used.3

Please select the option that best describes how this vehicle will primarily be used.

How many miles does this vehicle commute each way?3

How many miles does this vehicle commute each way?

Please provide details about the usage of this vehicle.3

Please provide details about the usage of this vehicle.

What type of coverage would you like for this vehicle?3

What type of coverage would you like for this vehicle?

Full coverage
Liability only
Not sure

What deductible option would you like for comprehensive coverage on this vehicle?3

What deductible option would you like for comprehensive coverage on this vehicle?

What deductible option would you like for collision coverage on this vehicle?3

What deductible option would you like for collision coverage on this vehicle?

Has any custom work been done to this vehicle?3

Has any custom work been done to this vehicle?

Yes
No

What is the value of the work that was done to this vehicle?3

What is the value of the work that was done to this vehicle?

Please provide a description of the custom work that was done to this vehicle.3

Please provide a description of the custom work that was done to this vehicle.

Is this vehicle currently being repaired/restored?3

Is this vehicle currently being repaired/restored?

Yes
No

What is the expected completion date?3

What is the expected completion date?

What is the name of the shop where the car is being repaired/restored?3

What is the name of the shop where the car is being repaired/restored?

What is the address of the shop where the vehicle is being repaired/restored?3

What is the address of the shop where the vehicle is being repaired/restored?

Street Address Address Line 2 City State ZIP Code

Will the original horsepower be increased or modified during this renovation?3

Will the original horsepower be increased or modified during this renovation?

Yes
No

Please provide details about the horsepower modification:3

Please provide details about the horsepower modification:

Will the engine, suspension, body, or drivetrain be changed during this renovation?3

Will the engine, suspension, body, or drivetrain be changed during this renovation?

Yes
No

Please provide details about the engine, suspension, body, or drivetrain changes.3

Please provide details about the engine, suspension, body, or drivetrain changes.

Please provide a description of the renovation currently underway.3

Please provide a description of the renovation currently underway.

Please upload up to three pictures of the vehicle here:3

Please upload up to three pictures of the vehicle here:

Drop files here or

Max. file size: 128 MB, Max. files: 3.

Collector Car #4

Please enter the year, make, model, body type and VIN. *4*

Please enter the year, make, model, body type and VIN. *

Year, Make, Model, Body Type	Vehicle Identification Number

Please select the category that best suites this vehicle.4

Please select the category that best suites this vehicle.

Are you in the process of purchasing this collector car? *4*

Are you in the process of purchasing this collector car? *

Yes
No

What date will you pick up the vehicle? *4*

What date will you pick up the vehicle? *

What date did you acquire this vehicle? *4*

What date did you acquire this vehicle? *

Will you be financing this purchase?4

Will you be financing this purchase?

Yes
No

Does this vehicle have a lien holder?4

Does this vehicle have a lien holder?

Yes
No

What is the name of the lien holder for this vehicle?4

What is the name of the lien holder for this vehicle?

What is the address of the lien holder for this vehicle?4

What is the address of the lien holder for this vehicle?

Street Address Address Line 2 City State ZIP Code

What is the registration state? *4*

What is the registration state? *

How many years have you owned this vehicle?4

How many years have you owned this vehicle?

Please rate the condition of this vehicle on a scale of 1 to 100. (100 = Perfection)4

Please rate the condition of this vehicle on a scale of 1 to 100. (100 = Perfection)

What is the value of this vehicle?4

What is the value of this vehicle?

Do you have a current appraisal for this vehicle?4

Do you have a current appraisal for this vehicle?

Yes
No

Please upload a copy of the appraisal, if convenient.4

Please upload a copy of the appraisal, if convenient.

Drop files here or

Max. file size: 128 MB.

How many miles is this vehicle driven on an annual basis?4

How many miles is this vehicle driven on an annual basis?

What is the current odometer reading?4

What is the current odometer reading?

Is this a high performance vehicle?4

Is this a high performance vehicle?

Yes
No

Is this vehicle owned by a Business, Trust, LLC, Limited Partnership or other legal entity?4

Is this vehicle owned by a Business, Trust, LLC, Limited Partnership or other legal entity?

Yes
No

Will you title this vehicle in the name a Business, Trust, LLC, Limited Partnership or other legal entity?4

Will you title this vehicle in the name a Business, Trust, LLC, Limited Partnership or other legal entity?

Yes
No

Please provide the name in which this vehicle is titled.4

Please provide the name in which this vehicle is titled.

Please provide the name to which this vehicle will be titled.4

Please provide the name to which this vehicle will be titled.

Enter the name of the primary driver of this vehicle?4

Enter the name of the primary driver of this vehicle?

Please select the option that best describes how this vehicle will primarily be used.4

Please select the option that best describes how this vehicle will primarily be used.

How many miles does this vehicle commute each way?4

How many miles does this vehicle commute each way?

Please provide details about the usage of this vehicle.4

Please provide details about the usage of this vehicle.

What type of coverage would you like for this vehicle?4

What type of coverage would you like for this vehicle?

Full coverage
Liability only
Not sure

What deductible option would you like for comprehensive coverage on this vehicle?4

What deductible option would you like for comprehensive coverage on this vehicle?

What deductible option would you like for collision coverage on this vehicle?4

What deductible option would you like for collision coverage on this vehicle?

Has any custom work been done to this vehicle?4

Has any custom work been done to this vehicle?

Yes
No

What is the value of the work that was done to this vehicle?4

What is the value of the work that was done to this vehicle?

Please provide a description of the custom work that was done to this vehicle.4

Please provide a description of the custom work that was done to this vehicle.

Is this vehicle currently being repaired/restored?4

Is this vehicle currently being repaired/restored?

Yes
No

What is the expected completion date?4

What is the expected completion date?

What is the name of the shop where the car is being repaired/restored?4

What is the name of the shop where the car is being repaired/restored?

What is the address of the shop where the vehicle is being repaired/restored?4

What is the address of the shop where the vehicle is being repaired/restored?

Street Address Address Line 2 City State ZIP Code

Will the original horsepower be increased or modified during this renovation?4

Will the original horsepower be increased or modified during this renovation?

Yes
No

Please provide details about the horsepower modification:4

Please provide details about the horsepower modification:

Will the engine, suspension, body, or drivetrain be changed during this renovation?4

Will the engine, suspension, body, or drivetrain be changed during this renovation?

Yes
No

Please provide details about the engine, suspension, body, or drivetrain changes.4

Please provide details about the engine, suspension, body, or drivetrain changes.

Please provide a description of the renovation currently underway.4

Please provide a description of the renovation currently underway.

Please upload up to three pictures of the vehicle here:4

Please upload up to three pictures of the vehicle here:

Drop files here or

Max. file size: 128 MB, Max. files: 3.

Collector Car #5

Please enter the year, make, model, body type and VIN. *5*

Please enter the year, make, model, body type and VIN. *

Year, Make, Model, Body Type	Vehicle Identification Number

Please select the category that best suites this vehicle.5

Please select the category that best suites this vehicle.

Are you in the process of purchasing this collector car? *5*

Are you in the process of purchasing this collector car? *

Yes
No

What date will you pick up the vehicle? *5*

What date will you pick up the vehicle? *

What date did you acquire this vehicle? *5*

What date did you acquire this vehicle? *

Will you be financing this purchase?5

Will you be financing this purchase?

Yes
No

Does this vehicle have a lien holder?5

Does this vehicle have a lien holder?

Yes
No

What is the name of the lien holder for this vehicle?5

What is the name of the lien holder for this vehicle?

What is the address of the lien holder for this vehicle?5

What is the address of the lien holder for this vehicle?

Street Address Address Line 2 City State ZIP Code

What is the registration state? *5*

What is the registration state? *

How many years have you owned this vehicle?5

How many years have you owned this vehicle?

Please rate the condition of this vehicle on a scale of 1 to 100. (100 = Perfection)5

Please rate the condition of this vehicle on a scale of 1 to 100. (100 = Perfection)

What is the value of this vehicle?5

What is the value of this vehicle?

Do you have a current appraisal for this vehicle?5

Do you have a current appraisal for this vehicle?

Yes
No

Please upload a copy of the appraisal, if convenient.5

Please upload a copy of the appraisal, if convenient.

Drop files here or

Max. file size: 128 MB.

How many miles is this vehicle driven on an annual basis?5

How many miles is this vehicle driven on an annual basis?

What is the current odometer reading?5

What is the current odometer reading?

Is this a high performance vehicle?5

Is this a high performance vehicle?

Yes
No

Is this vehicle owned by a Business, Trust, LLC, Limited Partnership or other legal entity?5

Is this vehicle owned by a Business, Trust, LLC, Limited Partnership or other legal entity?

Yes
No

Will you title this vehicle in the name a Business, Trust, LLC, Limited Partnership or other legal entity?5

Will you title this vehicle in the name a Business, Trust, LLC, Limited Partnership or other legal entity?

Yes
No

Please provide the name in which this vehicle is titled.5

Please provide the name in which this vehicle is titled.

Please provide the name to which this vehicle will be titled.5

Please provide the name to which this vehicle will be titled.

Enter the name of the primary driver of this vehicle?5

Enter the name of the primary driver of this vehicle?

Please select the option that best describes how this vehicle will primarily be used.5

Please select the option that best describes how this vehicle will primarily be used.

How many miles does this vehicle commute each way?5

How many miles does this vehicle commute each way?

Please provide details about the usage of this vehicle.5

Please provide details about the usage of this vehicle.

What type of coverage would you like for this vehicle?5

What type of coverage would you like for this vehicle?

Full coverage
Liability only
Not sure

What deductible option would you like for comprehensive coverage on this vehicle?5

What deductible option would you like for comprehensive coverage on this vehicle?

What deductible option would you like for collision coverage on this vehicle?5

What deductible option would you like for collision coverage on this vehicle?

Has any custom work been done to this vehicle?5

Has any custom work been done to this vehicle?

Yes
No

What is the value of the work that was done to this vehicle?5

What is the value of the work that was done to this vehicle?

Please provide a description of the custom work that was done to this vehicle.5

Please provide a description of the custom work that was done to this vehicle.

Is this vehicle currently being repaired/restored?5

Is this vehicle currently being repaired/restored?

Yes
No

What is the expected completion date?5

What is the expected completion date?

What is the name of the shop where the car is being repaired/restored?5

What is the name of the shop where the car is being repaired/restored?

What is the address of the shop where the vehicle is being repaired/restored?5

What is the address of the shop where the vehicle is being repaired/restored?

Street Address Address Line 2 City State ZIP Code

Will the original horsepower be increased or modified during this renovation?5

Will the original horsepower be increased or modified during this renovation?

Yes
No

Please provide details about the horsepower modification:5

Please provide details about the horsepower modification:

Will the engine, suspension, body, or drivetrain be changed during this renovation?5

Will the engine, suspension, body, or drivetrain be changed during this renovation?

Yes
No

Please provide details about the engine, suspension, body, or drivetrain changes.5

Please provide details about the engine, suspension, body, or drivetrain changes.

Please provide a description of the renovation currently underway.5

Please provide a description of the renovation currently underway.

Please upload up to three pictures of the vehicle here:5

Please upload up to three pictures of the vehicle here:

Drop files here or

Max. file size: 128 MB, Max. files: 3.

Collector Car #6

Please enter the year, make, model, body type and VIN. *6*

Please enter the year, make, model, body type and VIN. *

Year, Make, Model, Body Type	Vehicle Identification Number

Please select the category that best suites this vehicle.6

Please select the category that best suites this vehicle.

Are you in the process of purchasing this collector car? *6*

Are you in the process of purchasing this collector car? *

Yes
No

What date will you pick up the vehicle? *6*

What date will you pick up the vehicle? *

What date did you acquire this vehicle? *6*

What date did you acquire this vehicle? *

Will you be financing this purchase?6

Will you be financing this purchase?

Yes
No

Does this vehicle have a lien holder?6

Does this vehicle have a lien holder?

Yes
No

What is the name of the lien holder for this vehicle?6

What is the name of the lien holder for this vehicle?

What is the address of the lien holder for this vehicle?6

What is the address of the lien holder for this vehicle?

Street Address Address Line 2 City State ZIP Code

What is the registration state? *6*

What is the registration state? *

How many years have you owned this vehicle?6

How many years have you owned this vehicle?

Please rate the condition of this vehicle on a scale of 1 to 100. (100 = Perfection)6

Please rate the condition of this vehicle on a scale of 1 to 100. (100 = Perfection)

What is the value of this vehicle?6

What is the value of this vehicle?

Do you have a current appraisal for this vehicle?6

Do you have a current appraisal for this vehicle?

Yes
No

Please upload a copy of the appraisal, if convenient.6

Please upload a copy of the appraisal, if convenient.

Drop files here or

Max. file size: 128 MB.

How many miles is this vehicle driven on an annual basis?6

How many miles is this vehicle driven on an annual basis?

What is the current odometer reading?6

What is the current odometer reading?

Is this a high performance vehicle?6

Is this a high performance vehicle?

Yes
No

Is this vehicle owned by a Business, Trust, LLC, Limited Partnership or other legal entity?6

Is this vehicle owned by a Business, Trust, LLC, Limited Partnership or other legal entity?

Yes
No

Will you title this vehicle in the name a Business, Trust, LLC, Limited Partnership or other legal entity?6

Will you title this vehicle in the name a Business, Trust, LLC, Limited Partnership or other legal entity?

Yes
No

Please provide the name in which this vehicle is titled.6

Please provide the name in which this vehicle is titled.

Please provide the name to which this vehicle will be titled.6

Please provide the name to which this vehicle will be titled.

Enter the name of the primary driver of this vehicle?6

Enter the name of the primary driver of this vehicle?

Please select the option that best describes how this vehicle will primarily be used.6

Please select the option that best describes how this vehicle will primarily be used.

How many miles does this vehicle commute each way?6

How many miles does this vehicle commute each way?

Please provide details about the usage of this vehicle.6

Please provide details about the usage of this vehicle.

What type of coverage would you like for this vehicle?6

What type of coverage would you like for this vehicle?

Full coverage
Liability only
Not sure

What deductible option would you like for comprehensive coverage on this vehicle?6

What deductible option would you like for comprehensive coverage on this vehicle?

What deductible option would you like for collision coverage on this vehicle?6

What deductible option would you like for collision coverage on this vehicle?

Has any custom work been done to this vehicle?6

Has any custom work been done to this vehicle?

Yes
No

What is the value of the work that was done to this vehicle?6

What is the value of the work that was done to this vehicle?

Please provide a description of the custom work that was done to this vehicle.6

Please provide a description of the custom work that was done to this vehicle.

Is this vehicle currently being repaired/restored?6

Is this vehicle currently being repaired/restored?

Yes
No

What is the expected completion date?6

What is the expected completion date?

What is the name of the shop where the car is being repaired/restored?6

What is the name of the shop where the car is being repaired/restored?

What is the address of the shop where the vehicle is being repaired/restored?6

What is the address of the shop where the vehicle is being repaired/restored?

Street Address Address Line 2 City State ZIP Code

Will the original horsepower be increased or modified during this renovation?6

Will the original horsepower be increased or modified during this renovation?

Yes
No

Please provide details about the horsepower modification:6

Please provide details about the horsepower modification:

Will the engine, suspension, body, or drivetrain be changed during this renovation?6

Will the engine, suspension, body, or drivetrain be changed during this renovation?

Yes
No

Please provide details about the engine, suspension, body, or drivetrain changes.6

Please provide details about the engine, suspension, body, or drivetrain changes.

Please provide a description of the renovation currently underway.6

Please provide a description of the renovation currently underway.

Please upload up to three pictures of the vehicle here:6

Please upload up to three pictures of the vehicle here:

Drop files here or

Max. file size: 128 MB, Max. files: 3.

Regular Use Vehicles

How many regular use cars do you own? **

How many regular use cars do you own? *

Please enter a number from 1 to 10.

Please enter the year, make and model for any regular use vehicles you own/lease.

Year	Make	Model

Supplemental Collector Car Questions

What is the total number of collector cars owned?

What is the total value of your car collection?

Are any collector vehicles used for race/rally or driven on a track?

Yes
No

Please provide details:

Are all collector vehicles stored in a garage?

Yes
No

Is the garage fully enclosed?

Yes
No

Is the garage kept locked?

Yes
No

Is there a security/fire detection system in the garage?

Yes
No

Please provide a brief description of the security/fire detection system.

Please describe your prior experience driving high performance vehicles.

Do you rent your collector car(s) to others? (Ie. Driveshare, Turo, Etc.)

Yes
No

Please provide details about the rental exposure in your collection.

Do you belong to any automobile clubs?

Yes
No

Please share the name of the automobile club(s) you belong to.

Additional Driver Information

How many additional drivers are there in your household? (Enter 0 for no additional drivers) **

How many additional drivers are there in your household? (Enter 0 for no additional drivers) *

Please enter a number from 0 to 10.

Please enter the below information for any additional drivers in the household.

Full name	Date of birth (mm/dd/yyyy)	Driver's License number	License state

Have there been any moving violations for any driver in the past five years? **

Have there been any moving violations for any driver in the past five years? *

Yes
No
Not sure

How many total violations have there been in your household in the last five years? **

How many total violations have there been in your household in the last five years? *

Please enter a number from 1 to 10.

Please list the driver name, date of violation, and a brief description of the moving violation(s) below.

Driver Name	Date of Violation	Moving Violation Detail

Have there been any automobile insurance claims in your household in the last five years? **

Have there been any automobile insurance claims in your household in the last five years? *

Yes
No

How many automobile insurance claims have there been in your household in the last five years? **

How many automobile insurance claims have there been in your household in the last five years? *

Please enter a number from 1 to 10.

Please provide details about the automobile insurance claim(s).

Date of Loss	Brief Description	Amount Received ($)

Documents and Comments

Please use this field to upload any relevant insurance documents. (ie. Current policy declarations pages, appraisals, etc...)

Drop files here or

Accepted file types: pdf, jpg, Max. file size: 128 MB, Max. files: 5.

Please enter any additional remarks in the space below.

How did you hear about us?

Please share who referred you to us.

Please share what you typed into Google.

Please share how you heard about us.

Consent*

Disclaimer: This online questionnaire is a tool used to gather information. It is not an application for insurance. No insurance coverage will be bound or put into effect by submitting this form.

Consumer disclosure: By checking the box below you authorize the Agency who supplied this form to you to contact you via phone, email, and text messaging; to save and share with business partners the information you provided; to obtain consumer reports that may include credit-based reports (where legally allowed), public records, claims history, and driving records so that they can give you accurate insurance quotes. *

I agree *

Collector Car Insurance Expanded Form

Collector Car #1

Collector Car #2

Collector Car #3

Collector Car #4

Collector Car #5

Collector Car #6

Regular Use Vehicles

Supplemental Collector Car Questions

Additional Driver Information

Documents and Comments

Veronica Benson

RiskRevu^TM Newsletter

Contact

Collector Car Insurance Expanded Form

Collector Car #1

Collector Car #2

Collector Car #3

Collector Car #4

Collector Car #5

Collector Car #6

Regular Use Vehicles

Supplemental Collector Car Questions

Additional Driver Information

Documents and Comments

Veronica Benson

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RiskRevuTM Newsletter

Contact

RiskRevu^TM Newsletter