New Form Test | Collector & Classic Car Insurance

Name*

First Last

Date of Birth*

Email Address*

Phone*

Are you a member of a National Level Car Club?*

Examples of National Level Car Club: National Corvette Museum, National Corvette Restorers Society, National Council of Corvette Clubs, Mustang Club of America, Porsche Club of America, BMW Club of America.

What National Level Club are you a member of?

Not a local or regional car club.

Vehicle Information

VIN

Year*

Make*

Model*

Sub-Model (Coupe, Convertible, Z06, etc)*

Agreed Value*

Has this vehicle been modified?*

Yes

No

Mileage Tier*

How many miles do you plan to drive the vehicle each year?

How long have you owned this vehicle?*

Would you like the 9-5 Endorsement?*

Yes

No

This gives you the ability to drive this vehicle to work up to 2 times per week.

Do you have additional collector vehicles to add?*

Yes

No

Additional Vehicle(s)

Add Additional Vehicle(s) Below

Year	Make	Model	Actions

There are no Vehicles.

Bodily Injury Liability & Property Damage*

Uninsured/Underinsured Bodily Injury*

What's your desired deductibles?

Comprehensive Deductible*

Collision Deductible*

Vehicle Information

Additional Vehicle(s)

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