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Angela Standish
2023-10-12T15:49:16-05:00
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Collector Vehicle Quote
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Agent First Name
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Applicant Information
Insured - First Name & Last Name
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DOB
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SSN
Current Mailing Address
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Country
United States (US)
United Kingdom (UK)
Canada
Australia
---
Afghanistan
Åland Islands
Albania
Algeria
Andorra
Angola
Anguilla
Antarctica
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American Samoa
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Belau
Belize
Benin
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Bolivia
Bonaire, Saint Eustatius and Saba
Bosnia and Herzegovina
Botswana
Bouvet Island
Brazil
British Indian Ocean Territory
British Virgin Islands
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
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Congo (Kinshasa)
Cook Islands
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French Southern Territories
Gabon
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Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
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Guatemala
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Guinea
Guinea-Bissau
Guyana
Haiti
Heard Island and McDonald Islands
Honduras
Hong Kong
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India
Indonesia
Iran
Iraq
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Isle of Man
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Ivory Coast
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Laos
Latvia
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Lesotho
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Libya
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Lithuania
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Macao S.A.R., China
Macedonia
Madagascar
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Malaysia
Maldives
Mali
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Marshall Islands
Martinique
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Mayotte
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New Caledonia
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Niger
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Niue
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Norway
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Pitcairn
Poland
Portugal
Qatar
Reunion
Romania
Russia
Rwanda
Saint Barthélemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin (French part)
Saint Martin (Dutch part)
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
San Marino
São Tomé and Príncipe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
South Africa
South Georgia/Sandwich Islands
South Korea
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard and Jan Mayen
Swaziland
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Trinidad and Tobago
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
Uruguay
Uzbekistan
Vanuatu
Vatican
Venezuela
Vietnam
Wallis and Futuna
Western Sahara
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Yemen
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City
State
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Zip code
Has applicant moved in last 6 months?
*
Yes
No
Prior Mailing Address
Country
United States (US)
United Kingdom (UK)
Canada
Australia
---
Afghanistan
Åland Islands
Albania
Algeria
Andorra
Angola
Anguilla
Antarctica
Antigua and Barbuda
Argentina
Armenia
Aruba
American Samoa
Austria
Azerbaijan
Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belau
Belize
Benin
Bermuda
Bhutan
Bolivia
Bonaire, Saint Eustatius and Saba
Bosnia and Herzegovina
Botswana
Bouvet Island
Brazil
British Indian Ocean Territory
British Virgin Islands
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo (Brazzaville)
Congo (Kinshasa)
Cook Islands
Costa Rica
Croatia
Cuba
CuraÇao
Cyprus
Czech Republic
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Guiana
French Polynesia
French Southern Territories
Gabon
Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Heard Island and McDonald Islands
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Republic of Ireland
Isle of Man
Israel
Italy
Ivory Coast
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macao S.A.R., China
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
North Korea
Norway
Oman
Pakistan
Palestinian Territory
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn
Poland
Portugal
Qatar
Reunion
Romania
Russia
Rwanda
Saint Barthélemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin (French part)
Saint Martin (Dutch part)
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
San Marino
São Tomé and Príncipe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
South Africa
South Georgia/Sandwich Islands
South Korea
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard and Jan Mayen
Swaziland
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Trinidad and Tobago
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
Uruguay
Uzbekistan
Vanuatu
Vatican
Venezuela
Vietnam
Wallis and Futuna
Western Sahara
Western Samoa
Yemen
Zambia
Zimbabwe
City
State
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District Of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces (AA)
Armed Forces (AE)
Armed Forces (AP)
American Samoa
Guam
Northern Mariana Islands
Puerto Rico
US Minor Outlying Islands
US Virgin Islands
Zip code
Is the mailing address the same as the location address?
*
Yes
No
Location Address
*
Country
United States (US)
United Kingdom (UK)
Canada
Australia
---
Afghanistan
Åland Islands
Albania
Algeria
Andorra
Angola
Anguilla
Antarctica
Antigua and Barbuda
Argentina
Armenia
Aruba
American Samoa
Austria
Azerbaijan
Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belau
Belize
Benin
Bermuda
Bhutan
Bolivia
Bonaire, Saint Eustatius and Saba
Bosnia and Herzegovina
Botswana
Bouvet Island
Brazil
British Indian Ocean Territory
British Virgin Islands
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo (Brazzaville)
Congo (Kinshasa)
Cook Islands
Costa Rica
Croatia
Cuba
CuraÇao
Cyprus
Czech Republic
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Guiana
French Polynesia
French Southern Territories
Gabon
Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Heard Island and McDonald Islands
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Republic of Ireland
Isle of Man
Israel
Italy
Ivory Coast
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macao S.A.R., China
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
North Korea
Norway
Oman
Pakistan
Palestinian Territory
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn
Poland
Portugal
Qatar
Reunion
Romania
Russia
Rwanda
Saint Barthélemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin (French part)
Saint Martin (Dutch part)
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
San Marino
São Tomé and Príncipe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
South Africa
South Georgia/Sandwich Islands
South Korea
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard and Jan Mayen
Swaziland
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Trinidad and Tobago
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
Uruguay
Uzbekistan
Vanuatu
Vatican
Venezuela
Vietnam
Wallis and Futuna
Western Sahara
Western Samoa
Yemen
Zambia
Zimbabwe
City
State
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District Of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces (AA)
Armed Forces (AE)
Armed Forces (AP)
American Samoa
Guam
Northern Mariana Islands
Puerto Rico
US Minor Outlying Islands
US Virgin Islands
Zip code
Email
Primary Phone number
*
**If any of the following apply, customer is not eligible for coverage: Requires an SR-22 financial responsibility filing, any vehicle held for sale or consignment, operator convicted of a felony, applicant or operator had license suspended, canceled, revoked or barred within the last 3 years, customer is not the titled owner of the unit(s) or if any unit has unrepaired or existing damage.
Requested Effective Date
*
Discounts & Surcharges (check all that apply)
*
More than 1 American Modern policy with Graham-Rogers
Applicant will be paying in full
Applicant enroll in paperless policy delivery
Applicant owns primary residence
American Modern Policy Number:
*
Email
Has the applicant had continuous insurance or a lapse of less than or equal to 31 days?
*
Yes
No
Operator Information: List all licensed household members & regular use operators
Operator 1 (Named Insured)
Drivers
First Name
*
Last Name
*
Date of Brith
*
Gender
*
Male
Female
Marital Status
*
Single
Married
Divorced
Separated
Widowed
Spouse is required to be listed as operator and may be excluded if requested.
Member of any association?
*
Yes
No
List Association
*
Completed safety course in last 3 years?
*
Yes
No
Date completed?
*
Accidents or violations in the last 5 years?
*
Yes
No
Describe: Include date, amount & fault:
*
Any other operators?
*
Yes
No
First Name
*
Last Name
*
Gender
*
Male
Female
Date of Brith
*
Marital Status
*
Single
Married
Divorced
Separated
Widowed
Relationship to insured
*
Spouse
Child
Other - Specify:
SSN
Member of any association?
*
Yes
No
List Association:
*
Driver 2 Accidents or violations in the last 5 years?
*
Yes
No
Driver 2 Describe: Include date, amount & fault:
*
Has Driver 2 completed safety course in last 3 years?
*
Yes
No
Date driver 2 completed?
*
Unit Information
Vehicle Type
*
Auto/Truck
Race Car
Specialty
Is this a Kit Car?
*
Yes
No
Kit Car Manufacturer
*
Description
*
VIN/Serial Number
*
Is this a state assigned VIN?
*
Yes
No
For homemade or rebuilt vehicles
Year
*
Make
*
Model
*
Body Type
*
Odometer Reading
*
Purchase date
*
Condition
*
Pristine
Excellent
Good
Fair
Value
*
Is the vehicle under renovation
*
Yes
No
Percentage of completion for renovation
25% Complete
50% Complete
80% Complete
90% Complete
Is the unit have any modifications?
*
Yes
No
Explain modifications:
Registered for Street use?
*
Yes
No
Mileage Plan
*
1,000
3,000
6,000
Freedom
How is the vehicle used? Check all that apply:
*
Occasional Pleasure Use
Occasional Commuting to Work
Back-Up Transportation
Business Use
Commercial Use
Daily Personal Use
Off-Road
Promotional Use
Rented to Others
Other
Explain usage:
*
Is the Storage address different than the location address?
*
Yes
No
Storage Address
*
Country
United States (US)
United Kingdom (UK)
Canada
Australia
---
Afghanistan
Åland Islands
Albania
Algeria
Andorra
Angola
Anguilla
Antarctica
Antigua and Barbuda
Argentina
Armenia
Aruba
American Samoa
Austria
Azerbaijan
Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belau
Belize
Benin
Bermuda
Bhutan
Bolivia
Bonaire, Saint Eustatius and Saba
Bosnia and Herzegovina
Botswana
Bouvet Island
Brazil
British Indian Ocean Territory
British Virgin Islands
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo (Brazzaville)
Congo (Kinshasa)
Cook Islands
Costa Rica
Croatia
Cuba
CuraÇao
Cyprus
Czech Republic
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Guiana
French Polynesia
French Southern Territories
Gabon
Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Heard Island and McDonald Islands
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Republic of Ireland
Isle of Man
Israel
Italy
Ivory Coast
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macao S.A.R., China
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
North Korea
Norway
Oman
Pakistan
Palestinian Territory
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn
Poland
Portugal
Qatar
Reunion
Romania
Russia
Rwanda
Saint Barthélemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin (French part)
Saint Martin (Dutch part)
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
San Marino
São Tomé and Príncipe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
South Africa
South Georgia/Sandwich Islands
South Korea
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard and Jan Mayen
Swaziland
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Trinidad and Tobago
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
Uruguay
Uzbekistan
Vanuatu
Vatican
Venezuela
Vietnam
Wallis and Futuna
Western Sahara
Western Samoa
Yemen
Zambia
Zimbabwe
City
State
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District Of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces (AA)
Armed Forces (AE)
Armed Forces (AP)
American Samoa
Guam
Northern Mariana Islands
Puerto Rico
US Minor Outlying Islands
US Virgin Islands
Zip code
Storage Type
*
Carport
Driveway/Off Street Parking
Locked Garage/Building/Barn
Marina
Parking Garage
Parking Lot
Rental Storage Unit
Other - Specify:
Storage Construction
*
Frame
Masonry
Other
Describe Other:
*
Alarms?
*
Active
Passive
None
Disabling Device?
*
Active
Passive
None
VIN Etching
*
Yes
No
Vehicle Recovery/Tracking System?
*
Yes
No
Does the storage building have any of the following?
*
None
Storage Local Fire Protection and Burglar Alarm
Storage Central Fire Protection and Burglar Alarm
Does the storage building have an automatic fire suppression system?
*
Yes
No
Does the storage building have any entry deterrents?
*
Yes
No
Coverages
Eligible Motorcycles 2 years or newer will be quoted with Replacement Cost or ACV Upon request. ATV/UTV/Golf Carts are not eligible for RCV.
Coverages requested (check all that apply)
*
Medical Payments
Uninsured Motorists
Automobilia
Diminishing Deductible
Collision
Appreciation Security
Storage Limitation Exclusion
Liability limits
*
$25,000/$50,000/$25,000
$50,000/$100,000/$25,000
$50,000/$100,000/$50,000
$100,000/$300,000/$50,000
$100,000/$300,000/$100,000
$250,000/$500,000/$100,000
$250,000/$500,000/$250,000
$300,000/$300,000/$100,000
$500,000/$500,000/$100,000
$500,000/$1,000,000/$500,000
Medical Payments
*
$1,000
$2,500
$5,000
$10,000
Uninsured Motorists
*
$25,000/$50,000
$50,000/$100,000
$100,000/$300,000
$250,000/$500,000
$300,000/$300,000
$500,000/$500,000
$500,000/$1,000,000
Spare Parts Coverage
*
Collector Coverage
*
Automobilia Coverage:
*
Automobilia Deductible
*
100
250
500
1,000
2,500
5,000
10,000
Settlement Option
*
Agreed Value
Stated Value
Deductible for Comprehensive:
*
$2,500
$100
$250
$500
$1,000
$5,000
$10,000
0%
1%
2%
3
4%
5%
10%
15%
20%
25%
Settlement Option
*
Agreed Value
Stated Value
Deductible for Collision:
*
$0
$100
$250
$500
$1,000
$2,500
$5,000
$10,000
Towing and Emergency Expense
*
75 (Included)
200
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