ABOUT US | CONTACT US | HOME

Insured's Name: Policy Number: Effective Date of Change: Add Vehicle: Year: Make : Model: Identification Number: Cost New: If Private passenger; Driven to Work or School: Under 15 Miles Over 15 Miles Pleasure If Truck Indicate Gross Vehicle Weight and Use: GVW 0 - 10,000 Lbs 10,000 - 20,000 Lbs 20,001 - 45,000 Lbs Over 45,000 Lbs Use Commercial Retail Service Radius of Operation: Local 0 - 50 Miles Intermediate 1 - 200 Miles Long Distance Over 200 Miles When Adding a Vehicle, Indicate who is the Loss Payee and Address. If an Additional Driver Please Specify. Certificate Holder: Additional Insured Loss Payee Holder's Name, Address & Loan Number if Required: Name Street or P.O. Box City State Zip Phone Fax Number E-Mail         Driver's Name D.O.B. State Licensed Drivers License Number Delete Vehicle: Year Make Model Identification Number Cost New Comments: Requested By: Date: E-mail Address:                  © Franklin Insurance Group 2008