SPECIALTY/MODIFIED VEHICLES FORM
(Example: Street Rods, Customs, Kits and Replicas.)
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Applicant’s Name:
Mailing Address:
Occupation:
Contact Number: Email:
VEHICLE USAGE
1. Are your collectible vehicles used for any purposes other than car club, hobby activities or an occasional pleasure drive?  If Yes, for what purposes?
Yes No
2. Are any collectible vehicles used for racing? Yes No
3. Are any collectible vehicles used for commercial purposes? Yes No
4. Are any collectible vehicles used for backup or substitute transportation? Yes No
5. What purpose are the collectible vehicles driven for?
6. What is the approximate annual miles to be driven?
DRIVER INFORMATION Complete for all licensed drivers in the household

No
Name (As shown on license)
Gender M/F
Marital S/M
Birthdate
No. Years Lic.
License Number / State
1
2

3
1. How many licensed drivers are in the household (include youthful drivers)?
2. Please list vehicles used as daily transportation for each driver in the household.
Year Make/Model Is this a company car? If yes, do you own the company?
Yes No Yes No
Yes No Yes No
Yes No Yes No
3. Has any driver in the household had an accident or violation in the past three years? Yes No
4. Has any driver in the household had his/her licensed revoked in the past three years? Yes No
If Yes to either question above, please complete below:
Driver Name
Describe Violation/Accident/Revocation
MM/DD/YY
Did Your Insurance Company Pay?

Amount of Claim Payment
Yes No
Yes No
Yes No
General Information
1. Are all collectible vehicles kept in completely enclosed, locked garage(s)? Please note: All vehicles must be garaged. Garage location Address Yes No

Garage Information: Brick Frame Burglar Alarm Fire Alarm
2. Is your collectible vehicle currently being restored?
If Yes, how much has been completed? %
Yes No
3. Which clubs or associations do you currently belong?
4. List any awards/national points won with your collectible vehicle:
5. Is your collectible vehicle currently insured?
If Yes, with what company?
Yes No
SPECIALTY/MODIFIED VEHICLES (Example: Street Rods, Customs, Kits and Replicas.)
Year
Make
Model
Body Type
VIN (Exactly as shown on registration)
Horsepower
Agreed Value
Odometer
Is vehicle registered or will be within 30 days? Yes No
Is vehicle registered historical? Yes No
Is this a replacement vehicle? Yes No
Is there a loss payee on this vehicle?
If Yes, loss payee name: 		Yes No
State vehicle is registered?  
Is registrant a business? Yes No
Is the registered owner a named insured? Yes No
Who is the principal driver of this vehicle?  
Who is vehicle registered to?  
Annual Mileage: 0 – 2500 2501 – 5000 5001 – 7500  
COVERAGES
Bodily Injury/Property Damage $100,000 $300,000 Other
Medical Payments $1,000 $5,00 Other
Uninsured Motorists $100,000 $300,000 Other
Underinsured Motorists $100,000 $300,000 Other
Towing Yes No  
Glass Coverage Yes No  
Additional Paint Yes No  
Comprehensive Deductible $100 $250 $500 $1,000
Collision Deductible $100 $250 $500 $1,000
Additional Comments:

IMPORTANT NOTE: This form is provided as a convenience to you. We will make a good faith effort to obtain competitive quotes for your review. Depending on the type of business, we may require more information and will contact you if necessary. Your submission of this form DOES NOT guarantee that any binding offers will be forthcoming from insurers we represent.