Contact Info: |
| Your name: |
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| Your address: |
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| Your E-mail address: |
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An inaccurate e-mail address means that you WILL NOT receive confirmation that we have received your policy change request and may delay or abort your change request completely. |
| Your policy number: |
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| The name of your insurer: |
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Coverage effective date: |
| What is the date that coverage on this car should begin (this must be today's date or a date in the future): |
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IF YOU HAVE ALREADY TAKEN POSSESSION OF THIS CAR, please use the Additional
Information section below to explain why the delay in reporting this
purchase and CONFIRM THAT THERE HAS NOT BEEN ANY ACCIDENT INVOLVING
THIS CAR. It may NOT be possible to backdate the coverage. WE WILL
LET YOU KNOW.
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Car Ownership |
| If the car is NOT leased, who is the registered owner? |
Me or
someone else
If someone else is the registered owner, please state that person's
name:
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| If there will be a loan against the car, please give us the name and address of the lending institution: |
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| If the car is leased, please give us the name and the address of the leasing company: |
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| Who will the car be leased to? |
Me or
someone else
If the car is leased to someone else, please state that person's name:
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Description of the Car: |
| Year |
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| Make |
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| Model |
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| What is the serial number (VIN) of the car? |
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| What is the actual purchase price (or value if leased): |
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| How will the car be used: |
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| If you chose commute, how far do you drive one way? |
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| Please tell us the estimated number of kilometers driven annually |
km |
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If the car is being purchased used, please tell us about any unrepaired
damage in the Additional Information section below.
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Drivers: |
| Who will be the principal or main driver of this car? |
Me or
someone else
If someone else will be the principal or main driver, please state that person's name:
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| Is this person already a driver listed on your policy? |
Yes
No
(if the answer is no, please report this driver separately)
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Coverages: |
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What optional coverages do you want on the car? Click here
for an explanation and then use your back button to return to this
spot.
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| Collision |
Yes
No; Deductible
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| Comprehensive |
Yes
No; Deductible
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| Loss of Use |
Yes
No
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| Non-owned automobile/drive other automobile coverage |
Yes
No
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NOTE: We will automatically add the mandatory coverages.
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Additional Information |
Please tell us any additional information that you feel is important
or ask us any questions about insurance on this car
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User Validation
Please select the image that contains a truck?
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