Add a Vehicle

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Add A Vehicle
Contact Information
	Current Auto Policy Number:
	Name on Policy:
	Your Name (if other than Insured):
	Email Address:
	Daytime Telephone Number:
New Vehicle Information
	Effective Date of Policy Change: (mm/dd/year)
	VIN #:
	Year of New Vehicle:
	Make of New Vehicle:
	Model of New Vehicle:
	Is this a purchase or lease:	Purchase Lease
	Body Type of New Vehicle:
	Title Holder/Registered Owner:
	Name of Principal Driver:
	Principal Driver's Relationship to Named Insured:
	Occasional Driver/Operator:
	Purchase Price:
	Lien Holder/Loss Payee Name:
	Lien Holder Address:
	Garage Address:
New Vehicle Desired Coverages:
	Vehicle Useage: (describe)
	Miles to work (one way):
	Deductibles:	Comprehensive Please Select No Coverage 250 500 1000 Other
		Collision Please Select No Coverage 250 500 1000 Other
	Anti-Lock Brakes:	Select Yes No
	Car Alarm:	Select Yes No
	Air Bags:	Select Yes No
	Rental Coverage:	Select Yes No
	Towing Coverage:	Select Yes No
Comments or Other Instructions:
Please Note: Insurance coverage cannot be bound without a written binder from our office.

  

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Useful Worksheets for Home & Auto

1. Auto Accident Report Form - (to keep in glove box)-PDF
2. Home Inventory Form - (complete before a loss occurs)-PDF
3. Memory Jogger - (for use with home inventory worksheet.)-PDF

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Brier Payne Meade, Topeka – (785) 233-1717
Brier Payne Meade, Kansas City – (913) 402-9576

Get Driving Direction To Our Locations