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Home > Customer Service > Collector Car Quote Information Form

Antique/Collector Car Quote Information Form

(* Required Field)

Name:

Disclaimer: No insurance coverage or policy change will take effect until a Hoffman Group associate advises you by phone or through written communication that coverage has been placed. If you need immediate service, please call us at (800) 826-4006.

Address:

City:

State:

Zip:

Phone:

E-mail:

Driver Information:

Driver Name	Date of Birth (MM/DD/YY)	SSN	Driver License #

Any accidents/tickets?

Please provide detail.

Vehicle Information:

Vehicle Year, Make & Model	Serial Number/VIN	Annual mileage	Principal Driver	Value of vehicle	Anti-lock Brakes

Liability Limits

Uninsured Motorist Limits

Medical Payments Limit

Comprehensive Deductible

Collision Deductible

Used only for shows, parades and exhibitions

Lienholder Information:

Bank Name & Address	Leased?	Applies to Vehicle?

Current Insurance Company

2 Berea Commons, Suite 10 Berea, Ohio 44017	5329 N. Abbe Road Suite 4A Elyria, Ohio 44035	5000 Foote Road Medina, Ohio 44256
	1.800.826.4006