Have you had any accidents, claims or convictions for your automobile in the last 3 years? * Yes    No

If Yes – What happened and when?

Have you had any accidents, claims or convictions for your automobile in the last 3 years? * Yes    No

Year, Make, Model of Car? *

Is your vehicle Stock, or Modified/Customized? * Stock    Modified/Customized    Not Applicable

Value according to an appraisal conducted within the past 3 years *

Liability * 1 Million

Coverage Required * Specified Perils
Insurer will only pay for losses caused by fire, theft, or attempted theft, lightening, windstorm, hail, or rising water, earthquake, explosion; riot or civil disturbance, falling or forced landing of aircraft or parts of aircraft; or the stranding, sinking, burning, derailment or collision of any kind of transport in or upon which a described automobile (motorcycle) is being carried on land or water. Comprehensive
Insurer will pay for losses, other than those covered by Collision or Upset including: Perils listed under Specified perils, falling or flying objects, missiles, and vandalism Collision or Upset
Insurer will pay for losses caused when a described automobile (motorcycle) is involved in a collision with another object or tips over. Object includes: another automobile that is attached to the automobile, the surface of the ground and any object in or on the ground. All Perils
This option combines the coverage of Collision or Upset and Comprehensive. This coverage includes loss or damage caused if a person who lives in your household steals a described automobile. Coverage also applies if an employee who drives or uses, services or repairs a described automobile, steals it. No Physical Damage Coverage