Add or Replace a Vehicle Request Form
What is your Name (Name on the Policy)?
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First Name
Last Name
What is your preferred E-mail?
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Phone Number
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Format: (000) 000-0000.
Will this vehicle replace an existing vehicle on the policy?
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Yes
No
What is the effective date you would like to request ADDING the vehicle? - Date entered is a request only, not a confirmation of change.
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Month
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Day
Year
Date
New Vehicle Information
What is the VIN?
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What year is the vehicle?
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What make is the vehicle?
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What model is the vehicle?
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How is the vehicle titled?
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How is the vehicle owned?
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Owned Outright (No Loan)
Owned with a Lienholder (With a Loan)
Leased
Other
If other, describe how the vehicle is owned
Please enter the name of your lender or leasing company (lienholder/lessor).
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What best describes your need for Loan or Lease GAP coverage?
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I do not need GAP coverage - My loan/lease is less than the value of my car
I do not need GAP coverage - I already have GAP coverage through my dealer
I do not already have GAP coverage
I'm not sure (We can help!)
Which of the following best describes the use for the vehicle?
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Pleasure (Drive less than 3 Miles to work/school)
Short Commute (Drive 4-15 Miles to work/school)
Long Commute (Drive 16+ Miles to work/school)
Business use (Drive personal vehicle to/from work appointments, meetings, or jobs)
Will this vehicle be used for any Transportation Network Services, such as Uber, Lyft, Amazon, Shipt, or DoorDash?
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Yes
No
Will this vehicle be used for any Peer-to-Peer vehicle sharing platform such as Turo or ZipCar?
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Yes
No
Who is the assigned driver for the new vehicle?
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First Name
Last Name
What is the garaging address for this vehicle?
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Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
What is the annual mileage (estimated or actual) for the vehicle?
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Note: Some carriers rate on this, and require verification for low mileage credits.
Which of the following safety features are present on your vehicle?
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Blind Spot Warning
Automatic Emergency Braking
Rear Backup Camera
Lane Departure Warning
Forward Collision Warning
Describe any existing vehicle damage - if no damage, state None
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Policy Coverage Information
What would you like your collision deductible to be?
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$250
$1,000
$500
$2,500
What would you like your comprehensive deductible to be?
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$250
$1,000
$500
$2,500
What would you like your glass deductible to be?
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0$ Glass Deductible
Same as the comprehensive deductible
Are you interested in telematics for additional discounts? *Prob need to define telematics
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Yes
No
Would you like to include towing and/or AAA
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Include Towing & Exclude AAA Membership
Exclude Towing & Quote AAA Membership
Include Towing & Quote AAA Membership
Exclude Towing & AAA Membership
How much rental reimbursement would you like to include?
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$35/day - $1,050 max
All Reasonable Expenses
$50/day - $1,500 max
Highest Available Carrier Limit
$75/day - $2,250 max
Exclude Rental Reimbursement
$100/day - $3,000 max
Additional Optional Coverages - when available
If eligible: Would you like to include Accident Forgiveness in your policy?
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Yes
No
Unsure, please advise (Availability depends on the carrier & driver history)
If eligible: Would you like to include coverage for New Car Replacement ?
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Yes
No
Unsure, please advise (Availability depends on the carrier & age of the car)
If eligible: Would you like to include coverage for Diminution of Value, the Perceived Reduction in Value After a Loss?
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Yes
No
Unsure, please advise (Availability depends on the carrier & age of the car)
Deleted Vehicle Information
What vehicle will be replaced? (Make, Model, Year)
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What is the effective date you would like to request DELETING the vehicle? - Date entered is a request only, not a confirmation of change.
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Month
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Day
Year
Date
Signature
Continue
Should be Empty: