Collector Cars

About You

Name:

Phone:

Home Address:

Email:

Sex:

Marital Status:

Multi-owner (more than one owner, not in the same household):

Names of Household Resident Operators:

Names of Regular Operators (Access to insured vehicle(s) more than 12 times a year):

Number of Other Vehicles in household available for Regular use:

Driving Record (Prior 36 Months)

Number of/Nature of Tickets (All Vehicles):

Number of/Nature of Accidents:

Coverage Information

What is the Per Occurrence Bodily Injury limit of the regular use auto policy:

What is the Per Occurrence Uninsured Motorist Bodily Injury limit of the regular use auto policy:

Liability Coverage Limits Requested:

Uninsured/Underinsured Coverage Requested:

Personal Injury Protection:

Nationwide Roadside Assistance:

Other than Collision Agreed Value Deductible:

Other than Collision Stated Value Deductible:

Note: Agreed Value Coverage provides the amount shown in the declaration page in the event of a total loss, and up to the amount shown or the necessary cost of repairs in the event of a partial loss. Stated Value provides the lesser of the Actual Cash Value of the unit, the amount shown on the declarations page, or the necessary cost of repairs in all situations.

Additional Spare Parts ($2000 incl): $

Full Safety Glass:

No coverage of any kind is bound or implied by submitting information via this online form. We will not distribute information to other parties other than for insurance underwriting purposes. In States where authorized, some companies may use credit information when determining best rate. By submitting this quote you authorize such use and agree to release us from any liability should this information be accidentally viewed by others. To knowingly provide false, incomplete or misleading facts or information for the purpose of obtaining insurance coverage is unlawful.

Western Insurance Agency Inc

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