New Vehicle Information Client Form

Congratulations On Your New Car!

What is your first name?

What is your last name?

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Client Full Name

What is your name?

What is your email address?

Please provide the dealership's contact information.

Sales Person Name	Phone #	Email	Fax #

Enter the vehicle identification number (VIN).

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

What is the purchase price or MSRP?

Bill of Sale / Lease Agreement Upload

Please upload a copy of the bill of sale or lease agreement.

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)

Max. file size: 128 MB.

This field is hidden when viewing the form

What date will you take ownership of the vehicle?

Registration Effective Date

What is the registration effective date?

What state will the vehicle be registered in?

Who will the primary driver of this vehicle be?

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 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 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?

What is the address where this vehicle will be garaged?

Street Address Address Line 2 City State ZIP Code

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.

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

Yes
No

Which vehicle are you replacing?

Sale / Turn in Date Old Vehicle

What date will you sell the old vehicle?

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

Yes
No

Plates Returned?

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

Yes
No

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

Yes
No
Not sure

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

Max. file size: 128 MB.

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

Congratulations On Your New Car!

Stacey Richard

RiskRevu^TM Newsletter

Contact

New Vehicle Information Client Form

Congratulations On Your New Car!

Stacey Richard

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RiskRevuTM Newsletter

Contact

RiskRevu^TM Newsletter