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VEHICLE 1 -
Deletion Only Requires Effective Date, Year, Make & Model, and the Last Six (6) Digits of the VIN
Add
Delete
Eff Date
(
mm/dd/yy
)
Year
Make, Model, Body Type
Vehicle ID Number
Cost New
$
Garage Location
(
City, St, Zip
)
GVW/GCVW
(
Trucks Only
)
Radius (
Miles
)
(
Trucks Only
)
Farthest Terminal (
City & State
)
(
Trucks Only
)
Comp Ded
$
Coll Ded
$
Additional Interest Name
Loss Payee
Add'l Insured
Address (
Include City, State, Zip
)
Loan Number
VEHICLE 2
Add
Delete
Eff Date
(
mm/dd/yy
)
Year
Make, Model, Body Type
Vehicle ID Number
Cost New
$
Garage Location
(
City, St, Zip
)
GVW/GCVW
(
Trucks Only
)
Radius (
Miles
)
(
Trucks Only
)
Farthest Terminal (
City & State
)
(
Trucks Only
)
Comp Ded
$
Coll Ded
$
Additional Interest Name
Loss Payee
Add'l Insured
Address (
Include City, State, Zip
)
Loan Number
VEHICLE 3
Add
Delete
Eff Date
(
mm/dd/yy
)
Year
Make, Model, Body Type
Vehicle ID Number
Cost New
$
Garage Location
(
City, St, Zip
)
GVW/GCVW
(
Trucks Only
)
Radius (
Miles
)
(
Trucks Only
)
Farthest Terminal (
City & State
)
(
Trucks Only
)
Comp Ded
$
Coll Ded
$
Additional Interest Name
Loss Payee
Add'l Insured
Address (
Include City, State, Zip
)
Loan Number
REMARKS
Describe special or custom equipment, serial numbers and cost
, e.g.,
mag wheels, custom paint, phones, sound equipment or attached equipment, etc. Indicate any vehicle
damage, broken glass, rebuilt, salvaged, modified or altered equipment. If a change of address, provide new address.
Send (cc: ) this form to an additional email:
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Address: 1041 W. 18th Street, Suite A204, Costa Mesa, CA 92627 Phone: (800) 987-5051
Copyright © 2008 Excelsure Insurance. All rights reserved.
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