Pilot Car Insurance
Program Application
6/9/2019 2 | Page
PO Box 458, Winchester, TN 37398
phone: (931) 313-5519
fax: (931) 967-1128
www.pilotcarinsurance.org
pilotcar@pilotcarinsurance.org
'
Vehicle'Schedule'
1. Year: ___________ Make, Model, Body Type: _______________________________________________
VIN: ________________________________ Garage City, State: _________________________________
Name as it appears on vehicle registration? _________________________________________________
Registered state? ______________________________________________________________________
Stated value of vehicle: _________________________________________________________________
Do you have a Lien Holder? m Yes m No
Lien Holder Name/Address ______________________________________________________________
____________________________________________________________________________________
Comprehensive (ACV) m $1,000 m $2,000 m $2,500
Collision (ACV) m $1,000 m $2,000 *Check Desired Deductible
2. Year: ___________ Make, Model, Body Type: _______________________________________________
VIN: ________________________________ Garage City, State: _________________________________
Name as it appears on vehicle registration? _________________________________________________
Registered state? ______________________________________________________________________
Stated value of vehicle: _________________________________________________________________
Do you have a Lien Holder? m Yes m No
Lien Holder Name/Address ______________________________________________________________
____________________________________________________________________________________
Comprehensive (ACV) m $1,000 m $2,000 m $2,500
Collision (ACV) m $1,000 m $2,000 *Check Desired Deductible
3. Year: ___________ Make, Model, Body Type: _______________________________________________
VIN: ________________________________ Garage City, State: _________________________________
Name as it appears on vehicle registration? _________________________________________________
Registered state? ______________________________________________________________________
Stated value of vehicle: _________________________________________________________________
Do you have a Lien Holder? m Yes m No
Lien Holder Name/Address ______________________________________________________________
____________________________________________________________________________________
Comprehensive (ACV) m $1,000 m $2,000 m $2,500
Collision (ACV) m $1,000 m $2,000 *Check Desired Deductible
Office use only: Symbol 7 applies to Liability, Medical Payments, Uninsured/Underinsured Motorist, Comprehensive, Collision, Symbol 8 for Liability.
Include BAP Plus on all autos with physical damage coverage
There are no radius or mileage restrictions with this program.