Collector Vehicle Quote

Agency Information

Agency Name *

Agency Code *

Email *

Agent First Name *

Agent Last Name *

Phone *

Applicant Information

Insured - First Name & Last Name *

DOB *

SSN

Current Mailing Address *

Country

City

State

Zip code

Has applicant moved in last 6 months? *

Yes

Prior Mailing Address

Country

City

State

Zip code

Is the mailing address the same as the location address? *

Yes

Location Address *

Country

City

State

Zip code

Primary Phone number *

**If any of the following apply, customer is not eligible for coverage: Requires an SR-22 financial responsibility filing, any vehicle held for sale or consignment, operator convicted of a felony, applicant or operator had license suspended, canceled, revoked or barred within the last 3 years, customer is not the titled owner of the unit(s) or if any unit has unrepaired or existing damage.

Requested Effective Date *

Discounts & Surcharges (check all that apply) *

More than 1 American Modern policy with Graham-Rogers

Applicant will be paying in full

Applicant enroll in paperless policy delivery

Applicant owns primary residence

American Modern Policy Number: *

Has the applicant had continuous insurance or a lapse of less than or equal to 31 days? *

Yes

Operator Information: List all licensed household members & regular use operators

Operator 1 (Named Insured)

Drivers

First Name *

Last Name *

Date of Brith *

Gender *

Male

Female

Spouse is required to be listed as operator and may be excluded if requested.

Member of any association? *

Yes

List Association *

Completed safety course in last 3 years? *

Yes

Date completed? *

Accidents or violations in the last 5 years? *

Yes

Describe: Include date, amount & fault: *

Any other operators? *

Yes

First Name *

Last Name *

Gender *

Male

Female

Date of Brith *

Relationship to insured *

Spouse

Child

Other - Specify:

SSN

Member of any association? *

Yes

List Association: *

Driver 2 Accidents or violations in the last 5 years? *

Yes

Driver 2 Describe: Include date, amount & fault: *

Has Driver 2 completed safety course in last 3 years? *

Yes

Date driver 2 completed? *

Unit Information

Vehicle Type *

Is this a Kit Car? *

Yes

Kit Car Manufacturer *

Description *

VIN/Serial Number *

Is this a state assigned VIN? *

Yes

For homemade or rebuilt vehicles

Year *

Make *

Model *

Body Type *

Odometer Reading *

Purchase date *

Condition *

Pristine

Excellent

Good

Fair

Value *

Is the vehicle under renovation *

Yes

Percentage of completion for renovation

Is the unit have any modifications? *

Yes

Explain modifications:

Registered for Street use? *

Yes

Mileage Plan *

Explain usage: *

Is the Storage address different than the location address? *

Yes

Storage Address *

Country

City

State

Zip code

Storage Construction *

Frame

Masonry

Other

Describe Other: *

Alarms? *

Active

Passive

None

Disabling Device? *

Active

Passive

None

VIN Etching *

Yes

Vehicle Recovery/Tracking System? *

Yes

Does the storage building have any of the following? *

None

Storage Local Fire Protection and Burglar Alarm

Storage Central Fire Protection and Burglar Alarm

Does the storage building have an automatic fire suppression system? *

Yes

Does the storage building have any entry deterrents? *

Yes

Coverages

Eligible Motorcycles 2 years or newer will be quoted with Replacement Cost or ACV Upon request. ATV/UTV/Golf Carts are not eligible for RCV.

Liability limits *

Medical Payments *

Uninsured Motorists *

Spare Parts Coverage *

Collector Coverage *

Automobilia Coverage: *

Automobilia Deductible *

Settlement Option *

Deductible for Comprehensive: *

Settlement Option *

Deductible for Collision: *

Towing and Emergency Expense *

Any Additional Questions or Comments? If there is more than 1 Unit, please provide responses for all of the Unit Information questions for each additional unit in this box.

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