New Vehicle Information - Client Form - NEW

Congratulations On Your New Car!

Insured 1 - First Name

What is your first name?

Insured 1 - Last Name

What is your last name?

Insured 1 - Email

What is your email address?

Registration Details

Registration Type

How will the vehicle be registered?

In a person's name
In the name of a business
In the name of a trust or LLC

Registrant's Name from License

Please list the registrant's name as it appears on their drivers license. (Click the plus sign to add multiple registrants.)

First	Middle	Last	Suffix

Business Name for Registration

What is the name of the business the vehicle will be registered under?

What is the name of the trust or LLC the vehicle will be registered under?

Registrant Address for ID Card

What is the registrant's address? (Note: This is the address that will appear on the insurance card.)

Street Address Address Line 2 City State ZIP Code

Registration Effective Date

What is the registration effective date?

Registration State

What state will the vehicle be registered in?

Vehicle Information

Year, Make, Model

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

Year	Make	Model

VIN Number

Please enter the vehicle identification number (VIN).

What is the purchase price or MSRP?

Purchase Type?

What type of purchase is this?

Lease
Financed
Cash Purchase

Lien Holder/Lessor Drop Down

Please select the lien holder/lessor for this vehicle. (If the company is not listed or the language is not precise, please choose "Other" and enter the details.)

Lien Holder/Lessor Other

Please enter the lien holder/lessor name and address.

Bill of Sale Upload Financed

Please upload a copy of the bill of sale.

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

Bill of Sale Upload Cash Purchase

Please upload a copy of the bill of sale.

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

Lease Agreement Upload

Please upload a copy of the lease agreement.

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

Window Sticker Upload

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

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

Additional Transaction Details

Primary Driver

Who will be the primary driver of this vehicle?

Garaging Location Address

What is the address where this vehicle will be garaged?

Street Address Address Line 2 City State ZIP Code

Replacing vehicle?*

Are you replacing a vehicle you currently own with this purchase? *

Yes
No

Replacement Vehicle?

Which vehicle are you replacing?

Sale / Turn in Date Old Vehicle

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

Transferring Plates?*

Will you transfer the plates from the old vehicle to the new one? *

Yes
No
Not sure

Plates Returned?

Did you return the license plates to the department of motor vehicles?

Yes
No

Plate Receipt?

Do you have a receipt for the license plates being returned to the Department of Motor Vehicles?

Yes
No
Not sure

Plate Receipt Upload

Please upload the license plate return receipt you received from the Department of Motor Vehicles.

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

Dealership/Seller Contact Info

Please provide contact information for the dealership/seller.

Name	Phone #	Email	Fax #

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

New Vehicle Information - Client Form - NEW

Congratulations On Your New Car!

Registration Details

Vehicle Information

Additional Transaction Details

Dealership/Seller Contact Info

Barbara Targum

RiskRevu^TM Newsletter

Contact

New Vehicle Information - Client Form - NEW

Congratulations On Your New Car!

Registration Details

Vehicle Information

Additional Transaction Details

Dealership/Seller Contact Info

Barbara Targum

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RiskRevuTM Newsletter

Contact

RiskRevu^TM Newsletter