Added Vehicle Name(s) of insured(s)1st insured: 2nd insured: How can we reach you: E-Mail Phone E-mail Address: Daytime Telephone #: Home telephone #: Fax #: New VehicleVehicle make: Year: Model: Condition at time of purchase: Purchase Date: Calendar Purchase Price: VIN (vehicle ID #): Any non-factory modifications to the vehicle: YesNo Any unrepaired damage: YesNo If yes, specify: Is vehicle leased or financed: NoLeasedFinanced Names and address of leasing company lien holder: Use of Vehicle: Pleasure Commuting Business Farming Other Comments (details if use is other): Kilometers traveled per year: 0-5000 5001-10000 10001-15000 15001-20000 20001-25000 25001-30000 30001-over How many kilometers one-way for daily commute: N/A 0-5 6-8 9-16 17-24 25+ Will adding this vehicle result in changes in use of other: YesNo Third party Liability coverage requested: $1,000,000 $2,000,000 Collision coverage and deductible requested: None$500$1000Higher If Higher, please specify: Comprehensive coverage and deductible requested: None$300$500Higher If higher, please specify: All perils coverage and deductible requested: None$500$1000Higher If higher, please specify: Driver #1Driver: Date of Birth: Calendar Driver type: Principal Occasional Driver #2Driver: Date of Birth: Calendar Driver type: Principal Occasional Driver #3Driver: Date of Birth: Calendar Effective DateWhen will this change be effective: Calendar About Your Insurance (Specify the policy to which this change applies)Company: Policy #: Additional Comments: Name of your broker: Security code: