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ANTIQUE AUTO INSURANCE QUOTE REQUEST
Complete the following information if you would like to obtain a quote on an Antique Auto insurance policy. Please understand this is not an application for insurance. An application will be sent to you if coverage is desired.
All information provided on this information sheet is confidential and will be used solely for the purpose of developing a quote for you.
Classic Care Insurance. Small to medium size vehicles used mainly for exhibitions, club activities, parades and other functions of public interest. This vehicle is not a regular car used for household errands, vacations or going to work. All vehicles must be kept in a locked garage and not left unattended when in use.
If your vehicle doesn't fit into this category, select one of the options below:
Business Auto if the auto is a business use vehicle.
Commercial Vehicle if the vehicle is a large size vehicle (2 1/2 ton or more) and used regularly in a business.
Public Auto if the vehicle is a taxi, limousine, bus or shuttle bus.
Auto quote is for small to medium size vehicles, vans, pick-up trucks, four wheel drives and station wagons used for personal use not related to business and registered to you or a household family member.
Garaging Information
What is your name?
Last
First
Middle
What is the garaging address?
Street
City
State
Zip
What is your telephone number?
Home
Work
What is your fax number?
Fax
What is your email address?
Email
Mailing Address
What is your mailing address? (if different from above)
Street
City
State
Zip
Driver Information
Driver 1
First Name
Last Name
Gender
Male
Female
Marital Status
Years Licensed
State Licensed
Occupation
Driver 2
First Name
Last Name
Gender
Male
Female
Marital Status
Years Licensed
State Licensed
Occupation
Driver 3
First Name
Last Name
Gender
Male
Female
Marital Status
Years Licensed
State Licensed
Occupation
Driver 4
First Name
Last Name
Gender
Male
Female
Marital Status
Years Licensed
State Licensed
Occupation
Vehicle Information
Vehicle 1
Year
Make
Model
I.D. Number
Value
Vehicle Status (Stock or Modified)
Is this vehicle secured in a locked garage?

Yes

No

Miles per year
Ownership
Vehicle 2
Year
Make
Model
I.D. Number
Value
Vehicle Status (Stock or Modified)
Is this vehicle secured in a locked garage?

Yes

No

Miles per year
Ownership
Vehicle 3
Year
Make
Model
I.D. Number
Value
Vehicle Status (Stock or Modified)
Is this vehicle secured in a locked garage?

Yes

No

Miles per year
Ownership
Vehicle 4
Year
Make
Model
I.D. Number
Value
Vehicle Status (Stock or Modified)
Is this vehicle secured in a locked garage?

Yes

No

Miles per year
Ownership
Violation Information
Last 3 years (minor violations)
Last 5 years (major violations)
  Driver 1 Driver 2 Driver 3 Driver 4
Minor violations - speeding, turn, stop sign, red light, etc.
Accidents - non chargeable
Accidents - chargeable
Major violations - drunk driving, reckless, hit and run, etc.
Coverage Information
  Bodily Injury Property Damage
Personal liability
Uninsured motorist
Medical payment  
Deductible Information
  Vehicle 1 Vehicle 2 Vehicle 3 Vehicle 4
Comp (theft)
Collision
Miscellaneous Information
Current Insurance Company
Expiration date
Current premium
Questions or comments
Best Time to Contact You
Please let us know the best time to call and discuss your quote.
Morning
Afternoon
Evening
Anytime
Or specify other:
     
 
Wm.Scott Carter Insurance Agency #0703360

1820 W Carson St. Ste 221 | Torrance, CA 90501
Phone 310-732-0023
Fax 866-234-0026
 
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