New Vehicle/Automobile Information - Dealership/Seller Form

Insured 1 - First Name

What is the client's first name?

What is the client's last name? **

What is the client's last name? *

Vehicle Registration Details

Please list the names (as they appear on their drivers license) of the people to whom the new vehicle will be registered: (First, Middle/MI, Last, Suffix) **

Please list the names (as they appear on their drivers license) of the people to whom the new vehicle will be registered: (First, Middle/MI, Last, Suffix) *

First	Middle/MI	Last	Suffix

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

What is the registration effective date?**

What is the registration effective date?*

What state will the vehicle be registered in?**

What state will the vehicle be registered in?*

New Vehicle Information

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

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

Year	Make	Model

Please enter the vehicle identification number (VIN).**

Please enter the vehicle identification number (VIN).*

Car Purchase Price/Value

What is the purchase price or MSRP, if leased?

Window Sticker Upload

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

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

Odometer Reading

What is the odometer reading?

License Plate Number

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.

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

Purchase Information

What type of purchase is this?**

What type of purchase is this?*

Lease
Financed
Cash Purchase

Lien Holder/Leasing Company Drop Down*

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

Lien Holder/Leasing Company Other*

Please enter the lien holder/leasing company 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.

Other Transaction Details

Replacement vehicle?

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

Yes
No
Not sure

Vehicle Being Sold/Turned In/Traded

Which vehicle are they replacing? (Year, make, model)

Year	Make	Model

Vehicle sale/turn in date

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

License Plate Transfer?

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

Yes
No
Not sure

Dealership/Seller Information

What is the name of the dealership/seller?**

What is the name of the dealership/seller?*

Please enter the name of the dealership/seller's contact who should receive the insurance documents?**

Please enter the name of the dealership/seller's contact who should receive the insurance documents?*

What is the dealership/seller's phone number?**

What is the dealership/seller's phone number?*

What is the dealership/seller's preferred delivery method for insurance documents?**

What is the dealership/seller's preferred delivery method for insurance documents?*

Email
Fax

Dealership/Seller Email 1

What is the dealership/seller's email address?

Dealership/Seller Fax 1

What is the dealership/seller's fax number?

Documents and Comments

Uploaded Documents

Please use this field to upload any other relevant information for this new vehicle. (i.e. Bill of sale, Lease agreement, RMV1, Plate Receipt, etc.).

Drop files here or

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

Additional Remarks

Please enter any additional remarks in the space below.

<font size="2" color="gray">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.*

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/Automobile Information - Dealership/Seller Form

Vehicle Registration Details

New Vehicle Information

Purchase Information

Other Transaction Details

Dealership/Seller Information

Documents and Comments

Agent Name

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New Vehicle/Automobile Information - Dealership/Seller Form

Vehicle Registration Details

New Vehicle Information

Purchase Information

Other Transaction Details

Dealership/Seller Information

Documents and Comments

Agent Name

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