Insurance Confirmation Request
Raceway Chrysler
Customer Information
Insurance Agent
*
Insurance Agent Email
*
example@example.com
Customer Name (First and Last)
*
First and Last Name
VIN
*
FULL VIN
Sale Price (Before Tax)
Lienholder Info
Lienholder
*
CIBC
TORONTO DOMINION (TD)
BANK OF NOVA SCOTIA
SCOTIA DEALER ADVANTAGE
BMO
RBC
DESJARDINS
NATIONAL BANK
SCI LEASING
Other
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Raceway Contact Info
Finance Manager
*
Please Select
Manjinder Benipal
Faizan Ansari
Taz Amiri
Finance Manager Email
*
example@example.com
Salesperson
*
Please Select
Bob Saeed
Dave Piccinin
Alberto Anaya
Arman Zarrinpour
Mario Laron
Shiv S
Mark Cuevas
Charlie Rojas
Shane Marsh
Jackie Nimeck
Sal Dellaterza
EJ Edwards
Salesperson Email
*
example@example.com
Upload Bill of Sale
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Note:
A copy of this form will be sent to the emails below:
Email #1 - Insurance Agent
example@example.com
Email #2 - Finance Manager
example@example.com
Email #3 - Salesperson
example@example.com
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