COLLECTOR VEHICLE INSURANCE APPLICATION OREGON

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					                     COLLECTOR VEHICLE INSURANCE APPLICATION
                                                                OREGON
Submission Requirements
   •   Signed and currently dated Application
   •   Signed and currently dated Privacy Notice
   •   Signed and currently dated State UM/UIM selection/rejection forms (if applicable)
   • A minimum of two clear photos which shows all 4 sides of the vehicle are required. Additional photos showing interior
       and / or engine can be submitted
   •   Copy of Vehicle Registration
   • Full Annual Premium (Did you sign your check?)

A.      APPLICANT INFORMATION
     Applicant Name:
     (Enter your name(s) as it(they) appears on your vehicle registration)
     Primary Address:        Street:                                                        City:
                             State:             Zip:                     County:
     Mailing Address:        Street:                                                        City:
                             State:             Zip:                     County:
     Phone:                                                E-Mail:
     Is the collector vehicle currently insured with another company?                                                             Yes         No
     If yes, indicate company:                                                 Current expiration date:
     Do you have automobile insurance which covers all regular use vehicles owned by members of the
     household?                                                                                                                   Yes         No
     Please list any collector vehicle club that you belong to:     

B.     HOUSEHOLD DRIVERS
     List all licensed residents and dependents and regular operators. Attach auto insurance declarations page showing coverages and
     limits for each regular vehicle, whether owned or company provided. Attach additional pages as needed.
                                                  Date of                                                    Driver’s License Number,
                                 Name              Birth             Relationship to Applicant               State and Expiration Date
     Applicant
                                                                                N/A
     Driver 2                                                    Spouse Parent        Child    Sibling
                                                                 Other:      

                                                                                                                 Does driver have a vehicle
                                  Marital Status                                    Sex
                                                                                                                      for regular use?
     Applicant               Married               Single                 Male                Female                 Yes               No
     Driver 2                Married               Single                 Male                Female                 Yes               No

C.    DRIVING RECORD
                    Has this driver had any                   Has this driver had his/her driver’s       Has this driver been convicted or a DUI,
                 previous “at-fault” losses in the          license revoked or suspended in the            reckless driving or evading a police
                          last 3 years?                                  last 3 years?                          officer in the last 3 years?
     Applicant          Yes                No                       Yes                    No                    Yes                      No
     Driver 2           Yes                No                       Yes                    No                    Yes                      No

D. IF YOU HAVE MORE THAN 3 VEHICLES, CHECK THIS BOX     AND COMPLETE SECTIONS E. –H. ONLY ON ADDITIONAL
COPIES OF THE APPLICATION UNTIL ALL VEHICLES ARE INCLUDED.




     Collector Vehicle Application - Oregon                         Page 1 of 4                                                 Ed. 06/2011
E.    VEHICLE STORAGE DETAILS
                Garage Construction Type                                               Garage Location Address
                  Frame         Brick                                      Street, City, State, Zip Code                                     County
     Garage 1
     Garage 2
     Garage 3

                                                       Garage Security (check all that apply)
                                          Guards/          Enclosed                                                      Central              Local
                       Sprinklered       Watchman/             &           Burglar            Fire                       Station               Fire
                                         Caretaker          Locked          Alarm        Extinguisher                   Fire Alarm            Alarm
     Garage 1
     Garage 2
     Garage 3

F.    COLLECTOR VEHICLE DETAILS
                                                                                                                              Purchase        Purchase
                Year        Make              Model                          VIN                               Value            Date           Price
     Veh. 1
     Veh. 2
     Veh. 3

                Associated Garage Location (enter Number from Section E. above)
     Veh. 1
     Veh. 2
     Veh. 3

     Additional Interest
     Veh. # __    Loan               Lease    Interest Type:   Additional Insured           Loss Payee   Loss Payee and Additional Insured
     Loan/Lease No.                                     Phone No.                                   Fax No.
     Additional Interest Name:
     Street:                                              City:                                                 State:            Zip:
     Phone:                                               Email:

                                                                                                                              Vehicle Condition
     Modification Type                                                                                                 Fair     Good       Excellent
     Veh. 1      Stock           High Performance        Modified/Custom           Replica/Kit/Reconstructed
     Veh. 2      Stock           High Performance        Modified/Custom           Replica/Kit/Reconstructed
     Veh. 3      Stock           High Performance        Modified/Custom           Replica/Kit/Reconstructed

     Modifications
               Engine, Body or Drive Train differ          Will the engine, body or drive train be                Has horsepower been altered?
                        from original?                                   changed?
     Veh. 1          Yes                 No                         Yes                   No                             Yes                     No
     Veh. 2          Yes                 No                         Yes                   No                             Yes                     No
     Veh. 3          Yes                 No                         Yes                   No                             Yes                     No

     Vehicle Type
     Veh. 1       Automobile            Pickup Truck       Other Truck           Motorcycle         Tractor        Other:
     Veh. 2       Automobile            Pickup Truck       Other Truck           Motorcycle         Tractor        Other:
     Veh. 3       Automobile            Pickup Truck       Other Truck           Motorcycle         Tractor        Other:

                                                        Vehicle Usage (check primary use)
                                                             Daily             Primary or                   To and From              Racing or Rallying
                Pleasure         Show          Club      Transportation    Secondary Vehicle               Work or School
     Veh. 1
     Veh. 2
     Veh. 3




     Collector Vehicle Application - Oregon                        Page 2 of 4                                                           Ed. 06/2011
                Other Usage: (Describe)                                                                               Annual Mileage
     Veh. 1
     Veh. 2
     Veh. 3

G.    COMMENTS:
     Please include any additional comments here:




H.    COVERAGES
                                                                                       Select Uninsured/Underinsured
                           Select Liability Limit                                        Motorist Bodily Injury Limit
                                                                                   (Cannot be higher than the Liability Limit)
           $100,000                                                         $75,000
           $300,000                                                         $100,000
           $500,000                                                         $300,000
           $1,000,000                                                       $500,000
                                                                            $1,000,000

             Select Optional Uninsured/Underinsured                                    Select the Deductible for Mandatory
             Motorist Property Damage Coverage Limit                                   Personal Injury Protection Coverage
           No Coverage                                                      $0
           $20,000                                                          $100
                                                                            $250

                   Select Physical Damage Coverage                                   Select Physical Damage Deductible
              (Comprehensive Coverage is Mandatory)                             (Cannot equal or exceed vehicle’s agreed value)
           Comprehensive                                                    $0
           Collision                                                        $500
                                                                            $1,000
                                                                            $2,000
                                                                            $5,000
                                                                            $10,000

I.      CONDITIONS – PLEASE READ BEFORE SIGNING
                         COVERAGE IS CONTINGENT UPON COMPLIANCE WITH THE FOLLOWING CONDITIONS:
     STORAGE:
     While not in use, my vehicle(s) will be kept at its principal storage address in a solidly constructed, completely enclosed and locked
     structure (unless the Company agrees otherwise).

     USE:
         1.     My vehicle(s) will be used on a limited basis consistent with the operation of a collectible vehicle such as occasional
                pleasure drives and club/hobby activities.
           2.   My vehicle(s) will not be used for regular driving such as driving to and from work or school, shopping, errands, general
                transportation, or back-up use.

     INSURED REGULAR USE AUTO:
         1. Each driver within my household has a separately insured regular use vehicle of which he or she is the primary operator.
         2. All of the regular use vehicles in my household are insured by a separate personal auto insurance policy (or if a business
            auto policy, with the appropriate personal liability endorsements), maintained in my name (if owned by me), in full force and
            effect for the entire term of this policy.
         3. In no event will this policy serve as my household’s only auto insurance.

     REPLICA / KIT CAR:
     As a condition of any coverage provided by Philadelphia Indemnity Insurance Company, you must register your vehicle within 5
     business days. Once your vehicle has been registered with the state and issued a VIN number please provide us with this information
     within 10 days. Upon receipt of this information, we shall issue you an updated Insurance ID card as well as provide the DMV in your
     state with evidence of coverage for your vehicle(s).




     Collector Vehicle Application – Ohio                        Page 3 of 4                                                 Ed. 06/2011
                                                      FRAUD NOTICE STATEMENT

RESIDENTS OF OREGON APPLICANTS: “ANY PERSON WHO KNOWINGLY AND WITH INTENT TO DEFRAUD OR SOLICIT ANOTHER TO
DEFRAUD AN INSURER: (1) BY SUBMITTING AN APPLICATION, OR (2) BY FILING A CLAIM CONTAINING A FALSE STATEMENT AS TO ANY
MATERIAL FACT, MAY BE VIOLATING STATE LAW.”


                                          Tired of saving paper copies of your policy?
                               Frustrated by not being able to find your policy when you need it?

 Include your e-mail address on the attached application so you can receive an electronic version instead of a paper
 version of your policy. This e-document can be saved to your computer or downloaded onto a cd for safe off-site
 storage.
          E-MAIL ADDRESS: _________________________________________________________________________________________

 Philadelphia Insurance Companies will e-mail insurance documents to you at your request. Please consider that while
 Philadelphia Insurance Companies takes appropriate care to protect your privacy, there is some risk of interception
 when sending confidential, personal information by e-mail or e-mail attachment.

 APPLICANT’S STATEMENT
 I acknowledge that I have read and understood this application in its entirety and that if Philadelphia Indemnity
 Insurance Company or its authorized representative agrees to issue a policy to me, coverage will be contingent on the
 truth, accuracy and completeness of the information I provided herein. I agree that this application and any materials
 submitted by me or at my direction with this application, shall be incorporated into and shall constitute a part of any
 policy issued, whether physically attached to the policy or not. Failure to comply with any of the above conditions may
 result in coverage being voided or a claim being denied.

 Insurance coverage is subject to the terms, conditions, and exclusions in the policy.

                        THERE IS NO COVERAGE IN PLACE UNTIL YOU RECEIVE SPECIFIC NOTIFICATION FROM US.

PROPOSED EFFECTIVE DATE:                      APPLICANT SIGNATURE:                                  DATE:


Producer:


                                                                       NORTHWEST CLASSIC INSURANCE, INC.
                                                                            17401 135th Avenue NE #7
                                                                             Woodinville, WA 98072
                                                                                 800.683.1165




Collector Vehicle Application – Ohio                     Page 4 of 4                                        Ed. 06/2011

				
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