Custom & Modified Vehicle Worksheet NameThis field is for validation purposes and should be left unchanged.CUSTOM & MODIFIED VEHICLE WORKSHEET TO ACCURATELY PROTECT YOUR VEHICLE, FILL OUT THIS SHEET COMPLETELY. OWNER NAMESTATEVEHICLEVININTERIORAFTERMARKET GAUGES Yes No If yes, describeCUSTOM UPHOLSTERY Yes No If yes, describeSEAT BELTS STANDARD HARNESS OTHER FEATURESApproximate Cost for: Parts $Labor $STEREO & ELECTRONIC EQUIPMENT: If stereo systems, electronic equipment or audio/visual system are valued over $1,000 please describe:Approximate Cost for: Parts $Labor $ ENGINEENGINE ORIGINAL OTHER List Engine ManufacturerDisplacementApproximate horsepowerADDITIONAL POWER Turbo Supercharged Blower NITROUS Are there any nitrous components installed in the vehicle? Yes No TRANSMISSION TYPESHIFTING MECHANISMOTHER FEATURESApproximate cost for: Parts $Labor $EXTERIOR / FRAME / CHASSISBODY Steel Fiberglass Aluminum Other Describe body modificationsApproximate cost for: Parts $Labor $ANY SPECIAL PAINT/DETAILING WORK? Yes No If yes, describeApproximate cost for: Parts $Labor $FRAME / CHASSIS TYPE Stock Modified If modified, describeFront endRear endSUSPENSION TYPE AIR STOCK HYDRAULIC OTHER If modified, describeWHEELIE BARS YES NO TUBBED YES NO ROLL CAGE YES NO CUSTOM RIMS YES NO If yes, describeOTHER FEATURESApproximate cost for: Parts $Labor $APPLICANT SIGNATUREYour NameYour NameYour NameYour NameDate
