COLLECTOR VEHICLE INSURANCE APPLICATION
• 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
(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:
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
Driver 2 Spouse Parent Child Sibling
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 Security (check all that apply)
Guards/ Enclosed Central Local
Sprinklered Watchman/ & Burglar Fire Station Fire
Caretaker Locked Alarm Extinguisher Fire Alarm Alarm
F. COLLECTOR VEHICLE DETAILS
Year Make Model VIN Value Date Price
Associated Garage Location (enter Number from Section E. above)
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:
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
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
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
Collector Vehicle Application - Oregon Page 2 of 4 Ed. 06/2011
Other Usage: (Describe) Annual Mileage
Please include any additional comments here:
Select Liability Limit Motorist Bodily Injury Limit
(Cannot be higher than the Liability Limit)
Select Optional Uninsured/Underinsured Select the Deductible for Mandatory
Motorist Property Damage Coverage Limit Personal Injury Protection Coverage
No Coverage $0
Select Physical Damage Coverage Select Physical Damage Deductible
(Comprehensive Coverage is Mandatory) (Cannot equal or exceed vehicle’s agreed value)
I. CONDITIONS – PLEASE READ BEFORE SIGNING
COVERAGE IS CONTINGENT UPON COMPLIANCE WITH THE FOLLOWING CONDITIONS:
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).
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
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.
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:
NORTHWEST CLASSIC INSURANCE, INC.
17401 135th Avenue NE #7
Woodinville, WA 98072
Collector Vehicle Application – Ohio Page 4 of 4 Ed. 06/2011