* Required fields
E-mail Address *
Phone Number *
Date of Birth
Street Address *
Postal Zip Code *
Is your Collector Car registered to the above Address? *
Do you have Historic or Regular Plates
Historic Plates Regular Plates
Who is your Current Collector Auto Company?
Not Insured New Purchase Hagerty / One Beacon Grundy JC Taylor American Modern American Collectors Condon & Skelly Elite Collector Car Heacock Classic Auto Leland West Sneed Chrome Safeco Other
Number of Licensed Drivers in the Home?
1 2 3 4 5 6 7 8
How many Daily Use vehicles are there in the home?
Do any drivers in the home have a Felony Auto Conviction or DUI in the last 5 years? *
Do any licensed drivers in the home have any tickets or accidents in the last three years? If so brief explaination.
Are any operators of collector vehicles to be insured under 25 years old? *
What are the highest limits for your Daily Driver Auto Policy for Bodily Injury coverage?
Unknown $ 25,000 $ 50,000 $ 100,000 $ 300,000 $ 500,000
What are the highest limits for your Daily Driver Policy Uninsured/Underinsured coverage?
Unknown None. $ 25,000 $ 50,000 $ 100,000 $ 300,000 $ 500,000
Year, Make, Model of your Collector Car *
Agreed Value *
Expected Annual Mileage (once a week use averages to 1500 miles per year) *
Will the car/truck be driven to work? If so how often? *
Never Less than 5 times per year Less than 20 times per year Less than 60 times per year More than 60 times per year
Does the Vehicle have an Alarm?
None Active Alarm (must be mannually set) Passive Alarm (does not need to be manually set) GPS Locator System
Is your Collector Car kept in the Garage?
Garage Type *
Attached Enclosed Garage Attached Enclosed Garage with Monitored Alarm Detached Enclosed Garage Detached Enclosed Garage with Monitored Alarm Carport - Open on 3 or more sides Carport - Open on 1 sides Carport - Open on 2 sides Pole Barn Locked Trailer Secured Indoor Storage Other
Do you belong to any Automobile Clubs? Good Guy's, NSRA, Camaro Worldwide, etc, etc.
Are there any Veterans, Active Duty or Retired Military Members in the home?
No US Air Force US Army US Coast Guard US Marines US Navy US National Guard US Merchant Marines