Modified Vehicle / Street Rod Supplement CompanyThis field is for validation purposes and should be left unchanged.Applicant NameAgency Name : Hot Rod Insurance Services, Inc. 1870 El Camino Real, Ste 208 Burlingame, CAPolicy/Reference NumberA. PLEASE ANSWER THE FOLLOWING QUESTIONS:1. Purchase price of the vehicle2. Who built the vehicle:3. Have you had the vehicle(s) appraised in the past three years? Yes No (If “yes”, please attach a copy. Current appraisal required for vehicles over $50,000 in value)4. Have you had the vehicle(s) inspected in the past three years? Yes No (If “yes”, please attach a copy of the inspection to the application)5. Vehicle(s) used for any racing, on-track, or timed events? Yes No (If “yes”, please describe in comments section below).6. Vehicle(s) raised or lowered from original suspension height? Yes No (If “yes”, please describe in detail below in suspension section)7. Vehicle(s) equipped with: a. A fire extinguisher? b. Nitrous Oxide System? c. Any racing equipment? (If “yes” to b or c, please describe in comments section)B. LIST COMPONENTS & ANY MODIFICATIONS TO THE VEHICLE: Indicate type and manufacturer or parts where possible. This information will help expedite your settlement in the event of a loss. EngineHorsepowerCubic InchesBodySuspension & DifferentialWheels & TiresCommentsI attest that the above information is true and understand any misrepresentation of fact may affect any claims settlement. I understand that I have no coverage during any racing, track or timed events. Signature of ApplicantYour NameYour NameYour NameYour NameDate Florida Fraud Warning: Any person who knowingly and with intent to injure, defraud, or deceive any insurer files a statement of claim or an application containing any false, incomplete or misleading information is guilty of a felony of the third degree.
