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GRUNDY WORLDWIDE COLLECTOR VEHICLE PROGRAM .
PLEASE COMPLETE IN FULL Application
NAMED INSURED:
_________________________________________
(First) (Middle) (Last)
_______________________________________________
(Street)
____________________OR______________________________
(City) (State) (ZIP)
__________________________________x__________________
(Telephone) (Email)
____________________________________________________
(Occupation)
Schedule of Vehicle(s):
Estimated
Year of Condition Code
Make/Model/Body Type Vehicle ID No. Annual Agreed Value
Car (1-100- Perfection)
Mileage
PLEASE ANSWER THE FOLLOWING QUESTIONS AND EXPLAIN “YES” IN RESPONSES IN THE REMARKS SECTION
1. Preferred effective date of coverage? ______________________ 13. Total number of collector vehicles owned. _________
2. Previous loss or violations □Yes ■no 14. Operator information (all household operators)
(last three years) Name Date of Birth Driver’s License No.
3. Any operators under 25 years of age? □Yes ■no _____________ ______________ __________________
4. Any collector vehicle used for racing or _____________ ______________ __________________
rallying? □Yes ■no _____________ ______________ __________________
5. Any collector vehicle used for driving to and 15. List regular transportation vehicles for each driver
from work or school? □Yes ■no __________________________________________________
6. Any collector vehicle used for errands, __________________________________________________
back-up, primary or secondary transportation? □Yes ■no 16. To what automobile clubs do you belong to?
7. Does engine, body, or drivetrain differ from __________________________________________________
car maker’s original? ■Yes □no 17. Remarks (Explain Yes responses) ______________________
8. Will engine, body, or drivetrain be changed? □Yes ■no __________________________________________________
9. Will horsepower or body be changed? Yes ■no __________________________________________________
10. How many license operators in household? __________ __________________________________________________
11. Garage construction (describe walls and roof). __frame____ __________________________________________________
12. Any security systems? (fire or burglary). _locked____
I. Liability: Includes Medical Payments or PIP, Uninsured Your Quoted Premium Due = $_______
Motorist Coverage (statutory limit), and No Fault as required.
The following premium is applied only once for all vehicles Special rates applied to large collections. Some postwar vehicles
listed, annually. (Part I available only with Part II) subject to higher rates.
□$100,000 □$500,000 Note: Insurance becomes effective upon payment and acceptance of
■$300,000 risk
Applicant’s Statement: I warrant my collector vehicle will be used
II. Comprehensive Rate Including Collision: and maintained for hobby purposes and exhibition and not for
A) Thru 1945- Cost .55/$100 of insured value racing, rallying, general transportation, or backup transportation.
B) x After 1945 but 25 or more years old- Cost .65/$100 of insured value
C) Less than 25 years old- Cost 1.4/$100 of insured value
Submitting Brokerage
X
Signature Date
Underwritten by Philadelphia Insurance Companies
PHILY Broker Number: Northwest Insurance Center Inc.- 3477
Endorsement
DATE ISSUED: ENDORSEMENT NO:
INSURED: POLICY NO:
NAME OF COMPANY: EFFECTIVE DATE:
PRODUCER:
It is agreed and understood that the definition of “Antique Automobile” is deleted and replaced by the following:
“Antique Automobile” means:
(a) private passenger automobile
(b) a land motor vehicle other than a private passenger automobile principally designed for use on a public
highway; maintained solely for use in exhibitions, club activities, parades, or other functions of public
interest;
Furthermore, it is understood that no coverage will apply specifically for use other than exhibition, club activities,
parades, or other functions of public interest. Non-covered uses include but are not limited to driving to work, school,
errands, general transportation, secondary or back-up transportation, business or commercial purposes. Coverage will
not apply if the vehicle is used for racing, rallying or the participation in any speed contest, or time competitive event.
The Vehicle Can Be Used For Occasional Pleasure Driving.
Signed and accepted by:X_________________________________________________________
Notary:
All other terms and conditions remain unchanged
_______________________________
Authorized Signature
YOUTHFUL DRIVER ENDORSEMENT
PLEASE HAVE NOTARIZED
Date Issued Endorsement No. 3A
Insured Policy No.
Name of Company Effective Date
Producer JAMES A. GRUNDY AGENCY, INC
Effective TBA and in consideration of the premium charged, it is hereby understood and agreed that no
driver under the age of 25 years will be permitted to drive the vehicles insured under this policy and it is
further understood and agreed that coverage under this policy will not apply if a driver under 25 years of
age is permitted to drive any vehicle insured under this policy.
Signed & Accepted by: X_________________________
__________________________
NOTARY:
All Other Terms and Conditions Remain Unchanged ________________________
Authorized Representative
SELECTION OF LOWER LIMIT OF LIABILITY
FOR UNINSURED MOTORISTS COVERAGE
(OREGON)
Oregon Insurance Laws (ORS 742.502) permits you, the insured named in the policy, to select a limit of liability for Uninsured Motorists
Coverage lower than the limit for Bodily Injury Liability Coverage in the policy. Uninsured Motorists Coverage insures you, the insured, for all
amounts that you are legally entitled to recover as damages for bodily injury or death caused by accident and arising out of the ownership,
maintenance or use of an uninsured motor vehicle, subject to the terms of the policy.
Uninsured Motorists Coverage includes underinsured motorists coverage. Underinsured motorists coverage insures you, the insured, and others
covered under the Uninsured Motorists Coverage for damages to the extent that you Uninsured Motorists Coverage benefits are greater than the
amount recovered from other motor vehicle liability policies.
Comparison of prices for coverage:
□$100.00 is the price per vehicle for Uninsured Motorists Coverage at a limit equal to the bodily injury liability limit under the policy
issued or to be issued.
□$ No Charge/Included is the price per vehicle for Uninsured Motorists Coverage with a lower limit for Uninsured Motorists
Coverage, which I, a named insured, have requested.
X I, a named insured, elect a $300,000.00 limit of liability for Uninsured Motorists Coverage provided under the policy than the limit for
Bodily Injury Liability Coverage, I acknowledge that I was offered Uninsured Motorists Coverage at a limit equal to that for Bodily
Injury Liability Coverage.
This statement will remain in force until a named insured rescinds it in writing or until the motor vehicle bodily injury liability limits are
changed.
Signature and date (PLEASE NOTE: a named insured must sign and date this statement at the time a named insured elects lower limits.)
X___________________________________ ________________________________
SIGNATURE OF NAMED INSURED DATE OF SIGNATURE
Northwest Insurance Center, Inc.
Check list for Classic Car application:
#1 Completed and Signed Application
#2 Signed & Notarized Usage & Youthful Operator Endorsement Forms.
#3 Color Photos of each vehicle showing the general condition including Engine Compartment &
Interior.
#4 A check made payable to Grundy Worldwide in the amount of the annual premium.
#5 A copy of your insurance coverage page for your daily use vehicles. This page should display
the coverage limits for your vehicles.
Please note the following restrictions that apply:
1# Vehicle(s) may not be used to go to and from work or to run errands.
2# Persons under the age of 25 may not operate the vehicle.
3# Vehicle(s) must be stored in a locked garage when not being driven.
Please mail application to:
Northwest Insurance Center, Inc.
17401 135th Ave. NE suite #7
Woodinville, WA. 98072
If you have any questions please contact us:
Phone #: 425-483-5758 or 800-683-1165
E-mail: classiccars@gotinsurance.com
NO COVERAGE IS AFFORDED UNTIL YOU RECEIVE AN
INSURANCE IDENTIFICATION CARD FROM OUR OFFICE OR
PROOF OF CONFIRMATION.
