Replace Vehicle Name(s) of insured(s) 1st insured: 2nd insured: How can we reach you: E-mailPhone E-mail Address: Daytime Telephone #: Home telephone #: Fax #: Prior Vehicle Vehicle Make: Year: Model: New Vehicle Vehicle make: Year: Model: Condition at time of purchase: Purchase Date: Purchase Price: VIN (vehicle ID #): Any non-factory modifications to the vehicle: YesNo Any unrepaired damage: YesNo If yes, specify: Is vehicle leased or financed: NoLeasedFinanced Names and address of leasing company lien holder: Use of Vehicle: PleasureCommutingBusinessFarmingOther Comments (details if use is other): Kilometers traveled per year: 0-50005001-1000010001-1500015001-2000020001-2500025001-3000030001-over How many kilometers one-way for daily commute: N/A0-56-89-1617-2425+ Will adding this vehicle result in changes in use of other: YesNo Third party Liability coverage requested: $1,000,000$2,000,000 Collision coverage and deductible requested: None$500$1000Higher If Higher, please specify: Comprehensive coverage and deductible requested: None$300$500Higher If higher, please specify: All perils coverage and deductible requested: None$500$1000Higher If higher, please specify: Driver #1 Driver: Date of Birth: Driver type: PrincipalOccasional Driver #2 Driver: Date of Birth: Driver type: PrincipalOccasional Driver #3 Driver: Date of Birth: Effective Date When will this change be effective: About Your Insurance (Specify the policy to which this change applies) Company: Policy #: Additional Comments: Name of your broker:
