Fillable Collector Car Quote Request (Risk Placement Services, Inc.)

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Collector Car Quote Request (Risk Placement Services, Inc.)

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Collector Car Quote Request
Agent Information Customer Information
Agency Name:_____________________________
Agent #: __________________________________
Agent e-mail: ______________________________
Contact Person: ____________________________
Phone #: __________________________________
Fax #: ____________________________________
Name: ____________________________________
Address: __________________________________
City/State: _________________________________
Zip Code: _________________________________
DOB: ____________________________________
Marital Status
Married Single
Collector Car Information
Year: _____________
Manufacturer: ____________________________
Model: __________________________________
Market Value: ____________________________
Annual Miles Driven: ______________________
Under Restoration?
Yes No
If yes, % restored __________________________
Is vehicle owner business or corporation?
Yes No
Is vehicle kept in locked garage or facility?
Yes No
Garage State: _____________________________
Vehicle is:
Stock Modified
Vehicle is driven to:
Work School Daily Occasionally
Equipment includes:
Wheelie Bars
Roll Bar/Cage
Nitrous Oxide
5 point seat restraints
Drivers Information
Number of divers in the household: ______________________________
Are any drivers under age 26? Yes No Spouses cannot be excluded. (Refer for Underwriting)
Total number of accidents for all drivers in past 3 years: _________________________________
Total number of violations for all drivers in past 3 years: _________________________________
Coverage’s (Subject to Eligibility Minimums)
Liability Limits (Combine Split Limits): ______________________________
UM/UIM Limits (Combine Split Limits): _____________________________
Med Pay / PIP Limit: _____________________________________________
OTC/Collision Deductibles: ________________________________________
Other Vehicles
Year
Make Model Liability
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Collector Car Quote Request (Risk Placement Services, Inc.)

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Completed 30 July 2020

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