Auto Dealers New Auto Form

We will contact the insured/client to confirm before making any changes to the insurance policy

Date that vehicle was purchased: *

Client's name: *

Client's phone number: *

Name on title:

(if different)

Year: *

Make: *

Model: *

VIN #: *

Air bags: *

Anti-lock brakes: *

Anti-theft: *

Describe ownership of the vehicle: *

Was there a vehicle traded in: *

Dealer name: *

Phone number: *

Fax number: *

E-mail address: *

Dealer, proof of insurance will be emailed or faxed to you upon receipt of this form

We will then contact the insured to confirm coverages and add to their policy

Comments or additional information:

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