* Required fields
Name *
E-mail Address *
Phone Number *
Date of Birth *
Street Address
City
State
Postal Zip Code
What County do you live in?
How many Licensed Drivers are there in the home?
How many Daily Use Vehicles in the Home?
Does any operator to be insured have a D.U.I or Felony Auto conviction within the last five years?
Yes No
Do you or any other driver in the home have any accidents, tickets, or Insurance claims in the last 5 years?
Are any operators of the collector vehicle under 25 years old?
What is the Highest limit for your Daily Driver Auto Policy for Bodily Injury?
Unknown $25,000 $50,000 $100,000 $300,000 $500,000
What is the Highest limit of your Daily Driver Policy Uninsured/Underinsured Coverage?
Unknown None $25,000 $50,000 $100,000 $300,000 $500,000
What is the Year, Make, and Model of your New Collector Car? *
What is the Value of your Collector Car? *
If you are purchasing your car from a Dealership or Consignment shop please list which one and the stock number
Is your Vehicle kept in a Garage?
Yes No
Garage Type?
Attached Enclosed Garage Attached Enclosed Garage with Monitoring Alarm Detached Enclosed Garage Detached Enclosed Garage with Monitoring Alarm Carport open on all sides Carport open on 1 side Carport open on 2 sides Carports open on 3 sides Locked Trailer Secured Indoor Storage Communal Condo/Apartment Garage Other
Expected Annual Mileage (once a week use averages to 1500 miles per year)
Will the car be driven to work? *
No Less than 5 times per year Less than 20 times per year Less than 60 times per year More than 60 times per year
Will you be registering your car with Historic or Regular Plates?
Historic Plates Regular Plates
Do you own another Collector Car?
Yes No
Does the Vehicle have an Alarm?
None Active Alarm (must be manually set) Passive Alarm (does not need to be manually set)
Does your new Collector Car have a GPS Tracker?
Yes No
Are there any Veterans, Active Duty or Retired Military Members in the home?
no US Air Force US Army US Coast Guard US Marines US Navy US National Guard US Merchant Marines
Do you belong to any Automobile Clubs? Good Guy's, NSRA, Camaro Worldwide, etc, etc.
I have read and agree to the Privacy Policy *