Year:

Make:

Model:

Body type:

Does this vehicle replace another vehicle?:

VIN#:

Annual Mileage:

Principal driver:

Odometer reading:

Garaging location:

Anti-lock brakes: Yes: No: .

Driver AND passenger airbags: Yes: No: .

Anti-theft device: Yes: No: .

If yes, what type?:

Lienholder or leasing company name and address:

Liability coverage, medical payments uninsured motorist coverage: OR

same as existing policy: OR

Indicate changes in the text area to the right:

Comp and collision: /comp. deductible /coll. deductible OR

same as existing policy: OR

Indicate changes in the text area to the right:

Towing coverage: Yes: No: .

Rental reimbursement: Yes: No: .

If yes, $ per day / $ max

Waiver of collision deductible: No: .
( please note that this coverage applies only when insured is hit by an identifiable uninsured motorist )