ANTIQUE AUTO QUESTIONNAIRE
Insured:____________________________________________________ Policy # :______________________
Garaging location:_______________________________ City:______________ State:____ Zip:__________
DEFINITION OF ANTIQUE AUTO: An antique, classic, or collector’s automobile which is: (a) 25 or more years old; (b) maintained primarily for
use in exhibitions, club activities, parades and other functions of public interest; and (c) occasionally used for other purposes (such as limited
pleasure driving). Generally, a standard industry guideline is 2,500 miles per year or less.
To qualify for Antique Auto rating under a Fireman’s Fund auto policy, the following questionnaire must be completed and signed by
the registered owner of the antique auto(s).
Please complete all questions and attach the following items for each vehicle (place a check mark indicating each item is attached):
___ (a) Two photographs of auto – one of each side – showing condition of entire vehicle. **
___ (b) Does the insured have a Certified Classic/Antique Auto Appraisal? If so, please provide a copy of this appraisal.
** Pictures must be updated every three years
PART ONE:
LIST EACH ANTIQUE/COLLECTORS AUTO:
Year Make/ Model Who is primary
operator
Years
Owned
Condition (driveable but
needs body work;
completely restored)
Appraised
Value
Estimated
Annual
Mileage
Use, explain
$
$
$
$
PART TWO:
Yes No
___ ___ 1. Is any vehicle damaged or currently being restored? If yes, list details of the damage or restoration project; include projected
completion date of restoration:
________________________________________________________________________________________________________
________________________________________________________________________________________________________
___ ___ 2. Is any vehicle used for racing or rallying? If yes, explain:
________________________________________________________________________________________________________
________________________________________________________________________________________________________
___ ___ 3. Confirm that the vehicle(s) is(are) stored in a fully-enclosed and locked garage? If no, describe its storage; be specific about
security and access (provide a photo) and its construction (frame, brick, etc.):
________________________________________________________________________________________________________
________________________________________________________________________________________________________
I have read and completed this questionnaire in its entirety and declare that, to the best of my knowledge and belief, the
information I provide herein is complete, true and correct.
_____________________________________ _______________
Registered Owner/Insured Signature Date Signed (Ed. 04-2003)
click to sign
signature
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