APPLICATION FOR ANTIQUE & CLASSIC AUTO INSURANCE

J.C. Taylor Antique Automobile Agency, Inc.

320 South 69

Street, Upper Darby, PA 19082

Phone: 1-800-345-8290 – Toll Free Fax: 610-853-0114 www.JCTaylor.com

Applicant ___________________________________________ Date of Birth ______________ Occupation __________________

Street _______________________________________________ Phone Number _______________E-mail ____________________

City _____________________________________County ________________________State ______________ Zip ____________

List all Licensed Drivers in household:

DRIVER'S NAME

STATE & DRIVER'S

LICENSE NUMBER

DATE OF BIRTH

NUMBER OF YRS.

LICENSED

YEAR & MAKE OF VEHICLE DRIVEN

FOR DAILY USE

Co.

1.)

2.)

3.)

Attach a separate sheet for additional drivers. * If company vehicle, check (✓ )

The following coverages are available. Indicate your selections by placing an “X” in the proper box. All Rates are Annual Rates.

SINGLE LIMIT LIABILITY (VT = Verbal Tort Threshold) TOTAL

Liability(VT) – $100,000 Single Limit Bodily Injury and Property Damage - 1

Vehicle $19.50, 2

$13.00, 3

$6.50, Addl Veh. - No Charge $ _______

Liability(VT) – $300,000 Single Limit Bodily Injury and Property Damage - 1

Vehicle $26.00, 2

$18.20, 3

$10.40 Addl Veh. - No Charge _______

Liability – Other limits available. Please contact customer service for other limits and rates. ________________________ _______

Note: If you choose No Tort Threshold, double the above rates.

*Personal Injury Protection (standard) – $250,000 Combined Single Limit - 1

Vehicle $5.20, 2

$3.90, 3

$2.60, Addl Veh. - No Charge _______

*Additional Personal Injury Protection – Please contact customer service for limits and rates ________________________

*Uninsured/Underinsured Motorist Coverage – Please see the table on back for limits and rates and enter the proper premium.

__________________ 1

Vehicle _________ 2

Vehicle _________ 3

Vehicle _________ Addl. Veh. – No Charge. _______

*Selection/Rejection form may be required - see attached.

Physical Damage – Other than Collision (Comprehensive) Coverage – Annual Rates - $0.35/hundred for Vehicles 25 years or older _______

– Annual Rates - $0.70/hundred for Vehicles less than 25 years old _______

Physical Damage – Collision Coverage – Annual Rates - $0.35/hundred for Vehicles 25 years or older _______

– Annual Rates - $0.70/hundred for Vehicles less than 25 years old _______

Note: Collision Coverage is only available with Other than Collision (Comprehensive) Coverage

Towing & Roadside Assistance – $12.00 per Policy (Note: Only available with Collision Coverage) _______

Total Annual Premium $ ________

Requested effective date of coverage _____________________________ Minimum Policy Premium is $75.00

ANTIQUE VEHICLES TO BE INSURED**

We require: 1) Recent color photo of each vehicle listed, 2) A copy of your primary Auto Policy & 3) Payment in full at the time of submission of this application

YEAR MAKE

BODY TYPE

SERIES OR MODEL

VEHICLE IDENTIFICATION,

SERIAL OR MOTOR NUMBER

VALUE

IS THIS VEHICLE

REGISTERED?

(circle one)

STATE OF

REGIS-

TRATION

1) Yes No

2) Yes No

3) Yes No

4) Yes No

5) Yes No

Use separate sheet for additional vehicles to be insured.

Broker / Producer Information (if applicable)

Producer Name_______________________________________

Address _____________________________________________

City _______________________ State ______ Zip _________

Phone _____________________ Fax _____________________

E-mail ___________________________ I.D.# _____________

PRODUCER CANNOT BIND COVERAGE. NO COVERAGE IS PROVIDED

UNTIL J.C. TAYLOR OR THE INSURER BINDS COVERAGE.

** These vehicle(s) will be used mainly in exhibitions,

club activities, parades and other functions of public

interest and will not be used primarily for the

transportation of passengers or goods.

Important! See other side for

additional questions and required signature.

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J.C. Taylor Antique Automobile Agency, Inc.

320 South 69

Street • Upper Darby, PA 19082 • 1-800-345-8290 • Fax 610-853-0114 • www.JCTaylor.com

To properly expedite the handling of your application, please answer the following questions. Explain in detail for the necessary questions.

1. Have you or any driver in your household had any auto losses or moving violations in the past 3 years? If Yes, explain. _____ Yes _____ No

Include: Date-Cause-Payment.____________________________________________________________________________

2. Will you be using your antique/classic vehicle as a means of daily transportation, errands, or back-up? _____ Yes _____ No

3. Do you belong to an automobile club? If yes, which club?______________________________________________________ _____ Yes _____ No

4. Has (will) the body, engine, or drive train of the antique/classic vehicle been(be) changed?

If yes, explain _________________________________________________________________________________________ _____ Yes _____ No

5. Has the manufacturer's horsepower for your vehicle been changed? If yes, explain __________________________________ _____ Yes _____ No

6. Is any vehicle currently under restoration? If yes, a.) What is the expected date of completion? _________________________ _____ Yes _____ No

b.) If in shop, list name and address ________________________________________________________________________

7. Are all antique/classic vehicle(s) garaged? _____ Yes _____ No

8. Construction of garage: □ Cinder Block □ Brick/Stone □ Wood Frame □ Other (explain)_________________________________________________

Location(s) of garage(s) a.) Same as mailing address? □ Yes □ No If No, list full garage address ________________________________________

9. What is the annual mileage? (a) Club functions miles ________ (b) Other purpose miles_________ Explain ___________________________________

New Jersey Fraud Warning:

ANY PERSON WHO INCLUDES FALSE OR MISLEADING INFORMATION ON AN APPLICATION FOR AN INSURANCE

POLICY IS SUBJECT TO CRIMINAL AND CIVIL PENALTIES.

1.In connection with this application for insurance I agree that the insurer may secure and review consumer reports, including motor vehicle records for persons

listed in the application or subsequently added to the policy. I agree to allow the insurer to share my name, address, date of birth and social security number with

third party consumer reporting and insurance support organizations in order to obtain consumer reports. I further agree that the insurer may secure and review

new consumer reports in evaluating this policy, or for my request for a change in policy benefits, or for a replacement policy as permitted by law. I or my

authorized representative may request a copy of this authorization from my insurance representative.

2.I declare that the information contained in this application is true to the best of my knowledge and belief. I understand that the insurer will rely on this

information in determining my eligibility and premium.

3.I declare that the selections indicated in this application accurately reflect the limits, coverages and deductibles I chose.

4.I understand my producer is submitting this application to an appointed agency of an insurer, and that my producer does not have binding authority with the

insurer. I understand I will not have coverage until I am informed by the appointed agency or the insurer that coverage is bound or issued.

5.I agree that the insurer and its affiliates may use any telephone number, including any cell phone number, I provide now or in the future to contact me by way of

live calls or by use of any automatic dialing system or artificial or prerecorded voice.

My vehicle(s) will be used mainly in exhibitions, club activities, parades and other functions of public interest and will not be used primarily for the

transportation of passengers or goods. There is no coverage until specific notification is made by J.C. Taylor.

SIGNATURE OF APPLICANT(S) __________________________ DATE_____________

Rates for Uninsured Motorist Coverage (Includes Underinsured Motorist & UMPD)

Verbal Tort Threshold

Veh. 2

Veh. 3

Veh.

No Tort Threshold

Veh. 2

Veh. 3

Veh.

□ $35,000

$7.80 $7.80 $7.80

□ $35,000

$11.70 $11.70 $11.70

□ $100,000

$13.00 $13.00 $13.00

□ $100,000

$16.90 $16.90 $16.90

□ $300,000

$15.60 $15.60 $15.60

□ $300,000

$19.50 $19.50 $19.50

No Charge for Additional Vehicles. A $500 deductible applies to the Property Damage Uninsured Motorist Coverage.

Higher limits up to $500,000/$1,000,000 available upon request and with further underwriting review and copy of daily car policy. Please contact customer service for rates.

APPOINTED AGENCY J.C. Taylor APPOINTED AGENCY CODE 37-6790-999

Underwritten by Foremost Insurance Company Grand Rapids, Michigan

To effect insurance, we require payment of entire premium, completed forms, photos, compliance

with state regulations and our acceptance of risk. There is no coverage until the producer or applicant is notified by J.C. Taylor.

Check List ( ✓ )

( ) Signed, fully completed application ( ) Check for full premium (Payable to J.C. Taylor AAA)

( ) Signed state Selection/Rejection forms (if applicable) ( ) Copy of primary auto policy declarations page

( )

Recent, color photo of each vehicle. Photos may be e-mailed to [email protected] Date photos E-mailed: _________

( ) Appraisal required when insured value falls outside of standard hobby valuation guides

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