Hot Rod Quick Quote Sheet URLThis field is for validation purposes and should be left unchanged.Online rating, forms and program information is available at: www.hotrodins.com AGENCY INFORMATION Date AgencyContactPhone Fax application and supplemental form with the quoteAPPLICANT INFORMATION:NameGaraging StateInsurance Carrier for Daily Use VehiclesNumber of licensed drivers in the householdNumber of vehicles in household <15 yrsPlease check the following:There are operators with <10 years driving experience in the household. Yes No If yes, do these inexperienced operators drive the collectible auto(s)? Yes No Are the collectible vehicles we are quoting used for primary transportation including commuting, errands, and backup transportation? Yes No Any at-fault accidents and/or moving violations for any members in the household in the past 5 yrs.? Yes No If yes, DETAILS:VEHICLE INFORMATION (if >4 vehicles are to be quoted, copy this page and complete this section):YEARMAKEMODELLIST ANY VEHICLE MODIFICATIONSVEHICLE VALUEANNUAL MILEAGEGARAGE LOCATIONCOVERAGE REQUESTED: Please check limits desired - Basic Medical Payments and/or Personal Injury Protection will be quoted.Bodily Injury Liability $300,000 CSL $100,000 CSL State Minimum CSL 250/500/100 100/300/100 Other Uninsured / Underinsured $100,000 CSL $50,000 CSL State Minimum CSL 100/300/100 50/100/50 Other Physical Damage Comprehensive Collision Comp & Collision Deductibles 0 $250 $500 $1000
