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Client Add-Car Request Form
Switch Vehicle
**If you are replacing (same date) a vehicle, rather than just adding one, please use our Switch-Car Form link above.
* Indicates required question
Email
*
Your email
Policyholder Name (First, Last)
*
Your answer
Purchase date of new vehicle:
(Or desired effective date if vehicle was in storage)
*
MM
/
DD
/
YYYY
Vehicle Identification Number (VIN):
*
Your answer
Year, Make, & Model:
*
Your answer
Titled Owner(s):
Please list all names on title
*
Your answer
Estimated
Annual Mileage this vehicle will be driven:
(Typically 8,000 to 15,000 miles/year)
Annual Mileage Calculator
*
Your answer
Lienholder Name (bank that holds the loan)
If there is NOT a loan on the vehicle, please list "NONE"
*
Your answer
Please select the coverage for this vehicle
*
Full Coverage to match other vehicle(s)
Rental Reimbursement
Liability ONLY (No comprehensive or collision) + Road Service/Towing
Liability ONLY (No comprehensive or collision) and NO Road Service/Towing
Required
Will vehicle be used for Uber/Lyft/GrubHub?
*
No
Yes, and I agree to a small surcharge on the policy for the added risk exposure
Add any comments or special requests here:
Your answer
Submit
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