Hot Rod Program Application - Hot Rod Insurance Services, Inc

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EXTREMELY IMPORTANT: All Applicant and Vehicle information must be exactly as shown on Vehicle Registration to avoid state penalties. Please print clearly.

Applicant

Address

City/ST/Zip

Phone

Proposed Effective

Fax

Occupation

SS#

E-Mail

Year

Make/Model/Body Type

Titleholder Name & State

VIN Number

Odometer Reading

License Tag No

State

Vehicle Value - $

Date of Purchase

DRIVER INFORMATION (All members of household-licensed or not. Be sure to include children away from home.):

Name

Date of Birth

Sex

Marital Status

Relationship to Applicant

Drivers License Number

License State

CHECK PROGRAM & COVERAGE DESIRED (Coverages vary by state):

MILEAGE PLAN

1000/Yr

3000/Yr

5000/Yr

Other

LIABILITY COVERAGE (Same or lower limits than your family auto policy)

$25/50/25

$50/100/50

$100/300/100

$250/500/100

$500 CSL

Other

UNINSURED MOTORIST COVERAGE (Same or lower limits than your family auto policy)

No. U/M

$10/20

$25/50

$50/100

$100/300

$250/500

$500 CSL

Other

COMP & COLLISION

“0” Ded

$250 Ded.

$500 Ded.

Other

PROGRAM REQUIREMENTS:
(INITIAL–INDICATING THAT YOU WILL COMPLY WITH THESE REQUIREMENTS.)

Each licensed driver in household has a regularly daily-use vehicle.

Each daily-use vehicle carries Liability & Uninsured Motorist Coverage equal to or greater than coverage requested on this policy.

Vehicles Insured under this policy will be kept in a permanent enclosed and locked garage at all times when not in use.

Vehicles usage will not exceed the mileage plan selected

Vehicles insured under this policy will not be used for commuting to work or school, business use, daily transportation or as a substitute for another auto.

REQUIRED INFORMATION

Storage Location (if different)

Describe Storage Bldg. (age, construction use)

How many car events do you attend annually?

How many regular cars are owned by members of your household?

Name of your Family Auto Insurance Carrier

Liability & UM Limits on Family Auto Policy

UNDERWRITING QUESTIONS
In the past 3 years has any driver in your household:

A. Had their drivers license revoked?

Yes

B. Been convicted of a moving violation?

Yes

C. Been involved in a motor vehicle accident?

Yes

D. Been convicted of a drug or alcohol related violation?

Yes

E. Does any driver have any physical or mental impairment?

Yes

F. Has any driver been licensed less than 10 years?

Yes

G. Has your insurance ever been cancelled?

Yes

Please explain “yes” answers in remarks section

Collector Car Lienholder/Address

Remarks

THE FOLLOWING IMPORTANT CONDITIONS APPLY TO THIS INSURANCE:
1. Annual mileage is limited (based on plans elected) and usage is restricted to occasional pleasure driving, car shows, parades and club events.
2. Vehicles are not to be used for daily transportation, commuting, business, or to run errands.
3. Policy excludes racing, race testing, speed trials, any on-track or similar events.
4. Coverage does not apply when an insured vehicle is being operated by any driver with less than 10 years experience.
5. Physical damage coverage is based on “Stated Amount” unless stated otherwise.
6. You have no coverage until notified in writing by the Company.
Insurance coverage is subject to terms, conditions and exclusions in the policy. Always read your policy carefully
SUBMIT WITH APPLICATION:
1. Recent color photos showing all four sides of the vehicle(s).
2. Check for annual premium or Credit Card Payment payable to Infinity Insurance Company.

IMPORTANT NOTICE REGARDING THE FAIR CREDIT REPORTING ACT:
In making this application for insurance it is understood that as part of our underwriting procedure, an investigative consumer report may be prepared whereby information is obtained through personal interviews with your neighbors, friends, or others with whom you are acquainted. This inquiry includes information as to your character, general reputation, personal characteristics and mode of living. If an investigation is made, you can be assured that it will be handled in the strictest confidence.
If you wish information on the nature and scope of the Customer Report which may be requested, ask your agent for the address of the Company handling your account.

APPLICANT’S SIGNATURE

Date

LICENSED AGENT SIGNATURE

Date