MARKETING CODE ___________________
AGENT’S LICENSE #: _________________
498 Kings Highway North P.O. Box 8343 Cherry Hill, NJ 08002-0343
Telephone: 856-779-7212 or 800-360-2277 Fax 856-779-7289
MODIFIED VEHICLE APPLICATION - FLORIDA
PLEASE PRINT Underwritten By American Bankers Insurance Company of Florida
LAST NAME FIRST NAME MIDDLE INITIAL DAYTIME TELEPHONE NUMBER
ADDRESS CITY STATE ZIP CODE EMAIL ADDRESS
COMPLETE FOR ALL MEMBERS OF THE HOUSEHOLD (licensed, non-licensed and away at school)
DATE OF BIRTH DATES & DETAILS OF ALL ACCIDENTS, VIOLATIONS,
LICENSE SUSPENSIONS, FOR LAST 3 YEARS. ALSO MARITAL
NAME DRIVER’S LICENSE NUMBER COMPLETE FOR ANY DUI OR CARELESS DRIVING, OCCUPATION
MO. DAY YR. STATUS
REGARDLESS OF YEAR.
INSURED IF NONE
SPOUSE PLEASE INDICATE
CHILDREN IF NONE
CHILDREN PLEASE INDICATE
COLLECTOR VEHICLE INFORMATION
MODEL BODY PRINCIPAL ODOMETER
MAKE MODEL VEHICLE IDENTIFICATION NUMBER AGREED VALUE
YEAR TYPE DRIVER READING
1. Are all collector vehicles kept in an enclosed, locked and private garage? Yes No Address __________________________________________________________
2. Are listed vehicles used for any purpose other than club or hobby activities or an occasional drive? Yes No If yes, please explain _____________________________
3. Estimated annual mileage, collector vehicle: #1 ______________________________ #2 _______________________________ #3 _______________________________
4. Member of a local car club? Yes No If yes, which one? ______________________________________________________________________________________
5. Are listed vehicles used for any type of speed or timed event? Yes No If yes, please explain ________________________________________________________
6. Please list Lienholder of the modified vehicle, (if applicable): ___________________________________________________________________________________________
7. List ALL family cars in your household including non-owned or company cars available for your full-time use:
Year__________ Make________________________ Year__________ Make____________________________ Year__________ Make_______________________
8. What liability limits do you carry on your family autos? Bodily injury $ ________________ / $ ______________ Uninsured Motorists $_______________ / $ _______________
ONE VEHICLE TWO VEHICLES THREE OR MORE LIABILITY PREM.
$10,000/20,000/ $10,000/20,000/ $10,000/20,000/
LIABILITY includes bodily injury and $10,000 $100,000 $10,000 $100,000 $10,000 $100,000
property damage. Select your desired limit. $36 $60 $54 $90 $70 $118 $
PROPERTY DAMAGE LIABILITY
ONLY: $10,000 $36 $54 $70
PERSONAL INJURY PREM.
PERSONAL INJURY PROTECTION Please refer to the Florida Personal Injury Selection Form for available coverage limits and premiums.
Please complete, sign, and attach it to this application. $
Please refer to the Florida Uninsured Motorist Selection form for available coverage limits and premiums.
Please complete, sign, and attach it to this application. $
PHYSICAL DAMAGE RATES PER $100 OF AGREED VALUE
Physical Damage Coverage includes Inflation Guard; Spare Parts Coverage (up to $500); 30-days Automatic Coverage for newly purchased, qualifying vehicles
(up to $25,000); and Emergency Towing Reimbursement ($25). See reverse for additional towing & labor options. Please refer to Policy for complete coverage
descriptions and limitations.
DEDUCTIBLES NUMBER OF TOTAL COMPREHENSIVE & COLLISION PREMIUM
VEHICLES VEHICLE VALUES
Select Your $0 $ X $2.20 PER $100 OF VALUE $
Desired $250 $ X $1.90 PER $100 OF VALUE $
Deductible $500 $ X $1.60 PER $100 OF VALUE $
$1,000 $ X $1.30 PER $100 OF VALUE $
$50.00 minimum written premium All premiums are annual.
Comprehensive only coverage is available. Please call American Collectors for rates (800) 360-2277.
TOWING & LABOR FOR COLLECTORS (TLC) PLAN SILVER $9.95 per policy
GOLD PLAN $24.95 per policy
Plan applies to all vehicles on the policy. See reverse for coverage details. PLATINUM PLAN $34.95 per policy
INCREASED SPARE PARTS COVERAGE (SEE REVERSE FOR DETAILS) $1,000 $1,500 $
TOTAL ANNUAL PREMIUM $
M1963FLM-0108 IMPORTANT! SEE OVER FOR SIGNATURES Designed By: NS
ADDITIONAL COVERAGE OPTIONS
TOWING & LABOR FOR COLLECTORS (TLC) PLAN
Emergency Expense Coverage Endorsement
This optional coverage is designed for the insured whose collector vehicle has an emergency condition that occurs away from
the garaging address and should not be construed as a repair or maintenance service. It reimburses the insured for the expenses
described when an emergency condition occurs to a covered auto.
Silver Plan Gold Plan Platinum Plan
$100 Emergency Towing $150 Emergency Towing $250 Emergency Towing
$50 Roadside Assistance $100 Roadside Assistance $150 Roadside Assistance
$50 Emergency Lockout $50 Emergency Lockout $50 Emergency Lockout
Lost Key Return Service Lost Key Return Service Lost Key Return Service
$10,000 Accidental Death and $20,000 Accidental Death and
$250 Emergency Travel $500 Emergency Travel
$2,500 Theft Reward $5,000 Theft Reward
$250 Personal Effects $500 Personal Effects
$100 Ambulance Assistance $250 Ambulance Assistance
$100 Car Show Expenses $150 Car Show Expenses
$5,000 Bail Bond
$1,000 Legal Defense Benefit
$1,000 Hit and Run Reward
TrailerGuard $150 each
SPARE PARTS COVERAGE
We will pay up to $500 for direct and accidental loss to spare parts and accessories to your covered auto. The policy for which
you are applying automatically provides $500 of coverage. You may purchase an additional $500 or $1,000 of coverage.
1. Is any vehicle equipped with: air bags anti-lock brakes anti-theft devices VIN etching?
2. Has a principal operator completed an approved accident prevention course? Yes No *If yes, attach proof. Premium will be adjusted accordingly.
IMPORTANT! PLEASE READ AND SIGN
Florida Fraud Warning: Any person who knowingly and with intent to injure, defraud, or deceive any insurer files a statement of claim or an application
containing any false, incomplete, or misleading information is guilty of a felony of the third degree.
Limitations of Use: Insured vehicle(s) must be used primarily for club/hobby activities but may also be used occasionally for pleasure drives. Pleasure drives
do not include general transportation. Collector vehicle(s) cannot be used as temporary substitutes for a disabled and/or out-of-service and/or otherwise
unavailable family vehicle, nor for any timed racing event. This policy has a $50 minimum written premium. Your signature below attests to your understanding
of the foregoing. Please be sure to include a color photograph of each vehicle and a check for the total premium. Note: Photos become the property of American
Collectors and will not be returned. Coverage will begin upon American Collectors’ acceptance of the risk. There is no coverage until the Producer or
Applicant is so advised by American Collectors.
PROPOSED EFFECTIVE NAMED INSURED’S SIGNATURE TODAY’S DATE PRODUCER’S NAME PRODUCER’S SIGNATURE TODAY’S DATE
DATE (PLEASE PRINT)
Mo. Day Yr. X / / X / /
American Collectors has other insurance programs dedicated to Collector Motorcycles and other Collectibles.
For details or an application, call 1 (800) 360-2277 or visit our website at www.AmericanCollectors.com.