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+/- VEHICLE
Please complete this short form to request an additional vehicle be added to your policy.
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1
Name
Name of Insured requesting the change?
First Name
Last Name
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2
Email
example@example.com
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3
Process immediately or just a quote?
Process immediately once the required info is provided
Just a quote for a potential change
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4
Request type
Add a vehicle + Remove a vehicle
Add a vehicle only
Remove a vehicle only
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5
Vehicle Purchase Date
*
This field is required.
-
Date
Year
Month
Day
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6
Vehicle Info
*
This field is required.
Year
Make
Model
VIN Number
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7
Who is the registered owner(s)?
Please list co owners as well.
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8
Do you want physical damage coverage (full coverage) or liability only?
Choose to add or decline physical damage coverage for your vehicle
Full Coverage
Liability only
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9
Is there a loan or lease
YES
NO
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10
Who is the financing with?
We can add them to be sure they are notified of your coverage.
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11
Approximate Annual Miles Driven
Average is 12-15k
Please Select
0-1,000
1,000 - 3,000
3,000 - 5,000
5,000 - 7,000
7,000 - 9,000
9,000 - 11,000
11,000 - 13,000
13,000 - 15,000
15,000 +
Please Select
Please Select
0-1,000
1,000 - 3,000
3,000 - 5,000
5,000 - 7,000
7,000 - 9,000
9,000 - 11,000
11,000 - 13,000
13,000 - 15,000
15,000 +
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12
Does vehicle have more than $1,000 in permanently attached custom parts and equipment?
Tires, Wheels, Audio, Visual, Custom Paint, ets.
YES
NO
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13
Please provide brief description of each custom part and ballpark on value of each item.
We can add vehicle and follow up to collect more info if you are not sure at this time.
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14
Which Vehicle do you want to remove?
BE AWARE IF YOU STILL OWN THIS VEHICLE
. Once removed there is no coverage for anyone to drive (even a potential buyer test driving). You should maintain coverage until sold. If vehicle will not be driven for over a month, we may be able to offer storage insurance (theft, vandalism, fallen objects) for a lower cost.
You should notify DMV of a private sale in case the new owner does not register the vehicle in their name.
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15
Should we remove this vehicle effective the same date we are adding the new one?
If you bought and sold/traded in on different dates, we can process accordingly.
YES
NO
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16
What date should we remove this vehicle?
-
Date
Year
Month
Day
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17
Are there any questions or additional changes needed?
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