To request the addition of a vehicle to your classic policy, complete the information below in its entirety and return to our office with photos (see information below). Your request will be subject to approval. An incomplete form will delay processing. Insured name: ________________________________________ Policy # _________________________ Address: _____________________________________________________________________________________ Daytime phone: ____________________________ Fax: ___________________________ Email address: ___________________________________________ Year/Make/Model/Type: _____________________________________________________________ Vehicle identification number: _____________________________________________ (please place a line through the number zero, if applicable) Purchase Date:___________________ If a recent purchase, please provide Bill of Sale. Name exactly as shown on vehicle registration: _________________________________________ State of registration: ________________ Historically Registered Yes No Market value: $_______________ Current odometer reading:_________________________ Estimated annual mileage: ___________________________ Has vehicle been restored? Yes No If so, when? ___________ Overall condition: Fair Good Very Good Excellent Have there been any upgrades or modifications made to the vehicle, including engine replacement? If so, please list: ________________________________________________________________________________________________ _______________________________________________________________________________________________ Is vehicle kept in a permanent, locked, & enclosed garage when not in use? Yes No Garaging address, if different from mailing: __________________________________________________ Is there a loan on the vehicle? If so, provide name and address: ________________________________________________________________________________________________ Proposed effective date for this change: ________________________ Color photographs of the vehicle are required as follows: Stock vehicle: send 2 exterior photos showing entire car Modified or project vehicle: send 2 exterior, 1 engine compartment & 1 interior Email address for photos: [email protected] Please include your name and vehicle description in the subject line of the email. Signature: ___________________________ Date: ___________________________

To request the addition of a vehicle to your classic policy ......To request the addition of a vehicle to your classic policy, complete the information below in its entirety and return

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Page 1: To request the addition of a vehicle to your classic policy ......To request the addition of a vehicle to your classic policy, complete the information below in its entirety and return

To request the addition of a vehicle to your classic policy, complete the information below in its entirety and return to our office with photos (see information below). Your request will be subject to approval. An incomplete form will delay processing. Insured name: ________________________________________ Policy # _________________________ Address: _____________________________________________________________________________________ Daytime phone: ____________________________ Fax: ___________________________ Email address: ___________________________________________ Year/Make/Model/Type: _____________________________________________________________ Vehicle identification number: _____________________________________________ (please place a line through the number zero, if applicable) Purchase Date:___________________ If a recent purchase, please provide Bill of Sale. Name exactly as shown on vehicle registration: _________________________________________ State of registration: ________________ Historically Registered Yes No Market value: $_______________ Current odometer reading:_________________________ Estimated annual mileage: ___________________________ Has vehicle been restored? Yes No If so, when? ___________ Overall condition: Fair Good Very Good Excellent Have there been any upgrades or modifications made to the vehicle, including engine replacement? If so, please list: _______________________________________________________________________________________________________________________________________________________________________________________________Is vehicle kept in a permanent, locked, & enclosed garage when not in use? Yes No Garaging address, if different from mailing: __________________________________________________Is there a loan on the vehicle? If so, provide name and address: ________________________________________________________________________________________________Proposed effective date for this change: ________________________ Color photographs of the vehicle are required as follows: Stock vehicle: send 2 exterior photos showing entire car Modified or project vehicle: send 2 exterior, 1 engine compartment & 1 interior Email address for photos: [email protected] Please include your name and vehicle description in the subject line of the email. Signature: ___________________________ Date: ___________________________

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PO Box 24807 * Lakeland, FL * 33802 * Phone: 800-678-5173 * Fax: 863-686-1426