New Vehicle Information Dealer Form

What is the client's first name?

What is the client's last name?*

What is the client's last name?

What is the dealership name?*

What is the dealership name?

What is the dealership representative's name?*

What is the dealership representative's name?

What is the dealership's phone number?*

What is the dealership's phone number?

What is the dealership's preferred method for us to send you the insurance documents?

Email
Fax

What is the dealership's email address?

What is the dealership's fax number?

Enter the vehicle identification number (VIN).*

Enter the vehicle identification number (VIN).

What is the year, make, and model of the vehicle?

What is the purchase price or MSRP?

Registration effective date?*

What is the registration effective date?

Registration State*

What state will the vehicle be registered in?

Window Sticker Upload

Please upload a copy of the window sticker. (Required for vehicles valued greater than $100,000)

Max. file size: 128 MB.

What is the odometer reading?

What will the license plate number be?

Do you have a completed RTA (Registration and Title Application) form?

Yes
No

Please upload the RTA (Registration and Title Application) form.

Max. file size: 128 MB.

Registrant First Name

What is the first name of the person this vehicle will be registered to?

Registrant Middle Name/Initial

What is the middle name / middle initial of the person this vehicle will be registered to? (Enter as it appears on their license)

Registrant Last Name

What is the last name of the person this vehicle will be registered to?

What type of purchase is this?*

What type of purchase is this?

Lease
Financed
Cash Purchase

Lien Holder Drop Down

Please select the lien holder for this vehicle.

Lien Holder Other

Please enter the lien holder name and address.

Bill of Sale Upload Financed

Please upload a copy of the bill of sale.

Max. file size: 128 MB.

Bill of Sale Upload Cash Purchase

Please upload a copy of the bill of sale.

Max. file size: 128 MB.

Lease Agreement Upload

Please upload a copy of the lease agreement.

Max. file size: 128 MB.

Replacement vehicle?

Is the client replacing a vehicle they currently own with this purchase?

Yes
No

Which vehicle are they replacing?

Vehicle sale/turn in date

What date will the client sell / turn in the old vehicle?

Will the client transfer the plates from the old vehicle to the new one?

Yes
No

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.

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New Vehicle Information Dealer Form

Patrick Battle, CIC, CPRIA

RiskRevu^TM Newsletter

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New Vehicle Information Dealer Form

Patrick Battle, CIC, CPRIA

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RiskRevuTM Newsletter

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RiskRevu^TM Newsletter