Classic & Antique Auto Insurance Quote Request

This form is designed to gather the underwriting information necessary to quote classic & antique auto insurance policies.

Step 1 of 8

12%

First Named Insured

Name (as appears on your driver license)

First Middle Last Suffix

If your driver license includes your middle name or initial, please provide it above.

Phone

Gender

Marital Status

Date of Birth

MM slash DD slash YYYY

Driver License Number

Employment Status

What do you do for work?

Have you taken a defensive driving or accident prevention course in the last 3 years?

Yes

Date of Completion

MM slash DD slash YYYY

To receive this credit, we need to receive a copy of the completion certificate from you prior to binding the policy.

Insurance Score Consent

I authorize insurance companies to obtain and use my insurance score as part of the underwriting process. I understand this may involve a soft inquiry on my credit report, which will not affect my credit score.

SMS Consent

Disclaimer: By checking this box and submitting this form, you consent to receive SMS messages from Brooks Robb & Callahan at (516) 922-6500 about account notification and customer care. Message frequency may vary, and standard messaging and data rates may apply. Reply STOP to unsubscribe or HELP for assistance. For more details, see our Terms of Service and Privacy Policy and www.brcinsurance.com

Should a second named insured be listed on the policy (i.e., spouse, domestic partner)?

Yes

Second Named Insured

Name (as appears on your driver license)

First Middle Last Suffix

If you have a middle name or initial on your driver license, please add it above.

Phone

Gender

Marital Status

Date of Birth

MM slash DD slash YYYY

Driver License Number

Employment Status

What do you do for work?

Have you taken a defensive driving or accident prevention course in the last 3 years?

Yes

Date of Completion

MM slash DD slash YYYY

To receive this credit, we need to receive a copy of the completion certificate from you prior to binding the policy.

Relation to first person listed

Please describe

Insurance Score Consent

SMS Consent

How did you find our agency?

Referral

Google

Web Search

Walk-in / Drive-by

Other

Who referred you to us?

We want to know who to thank!

Please describe

Address Information

Mailing Address

Street Address Address Line 2 City State ZIP Code

Do you store your vehicle(s) at the mailing address listed above?

Yes

Vehicle/Property Address

Street Address Address Line 2 City State ZIP Code

Have you lived at a different address in the last 3 years?

Please provide information for additional other household members

Listed Vehicles

How many classic or antique vehicles will be insured on this policy?

Classic / Antique Vehicle 1

1. Year, Make & Model

1. Is this vehicle leased, financed or owned outright?

1. Agreed Value ($)

Agreed Value is a mutual agreement between you and the insurer that the scheduled limit is the item's true value and will be paid in full after a total loss, including all applicable taxes, fees, and registration costs.

1. Registration Type

1. Modification Type

Stock: Unmodified in any way // High Performance: Modified to increase or simulate greater performance // Modified Custom: Modified for personal styling // Replica/Kit/Reconstructed: Assembled by someone other than a licensed manufacturer, or materially altered from original construction

1. Please describe how this vehicle is garaged or stored when not in use.

For example: a locked private garage, an open carport, outdoor driveway, storage unit, climate-controlled facility, outdoors with cover.

1. Is this vehicle registered solely to the named insured(s) provided in Step 1 of this form?

Yes

1. Please provide the Registrant and Title Holder (if owned).

Classic / Antique Vehicle 2

2. Year, Make & Model

2. Is this vehicle leased, financed or owned outright?

2. Agreed Value ($)

2. Registration Type

2. Modification Type

2. Please describe how this vehicle is garaged or stored when not in use.

For example: a locked private garage, an open carport, outdoor driveway, storage unit, climate-controlled facility, outdoors with cover.

2. Is this vehicle registered solely to the named insured(s) provided in Step 1 of this form?

Yes

2. Please provide the Registrant and Title Holder (if owned).

Classic / Antique Vehicle 3

3. Year, Make & Model

3. Is this vehicle leased, financed or owned outright?

3. Agreed Value ($)

3. Registration Type

3. Modification Type

3. Please describe how this vehicle is garaged or stored when not in use.

For example: a locked private garage, an open carport, outdoor driveway, storage unit, climate-controlled facility, outdoors with cover.

3. Is this vehicle registered solely to the named insured(s) provided in Step 1 of this form?

Yes

3. Please provide the Registrant and Title Holder (if owned).

Classic / Antique Vehicle 4

4. Year, Make & Model

4. Is this vehicle leased, financed or owned outright?

4. Agreed Value ($)

4. Registration Type

4. Modification Type

4. Please describe how this vehicle is garaged or stored when not in use.

For example: a locked private garage, an open carport, outdoor driveway, storage unit, climate-controlled facility, outdoors with cover.

4. Is this vehicle registered solely to the named insured(s) provided in Step 1 of this form?

Yes

4. Please provide the Registrant and Title Holder (if owned).

Classic / Antique Vehicle 5

5. Year, Make & Model

5. Is this vehicle leased, financed or owned outright?

5. Agreed Value ($)

5. Registration Type

5. Modification Type

5. Please describe how this vehicle is garaged or stored when not in use.

For example: a locked private garage, an open carport, outdoor driveway, storage unit, climate-controlled facility, outdoors with cover.

5. Is this vehicle registered solely to the named insured(s) provided in Step 1 of this form?

Yes

5. Please provide the Registrant and Title Holder (if owned).

Additional Classic / Antique Vehicles

Year, Make, Model & Ownership (leased, financed, owned) of all Additional Vehicles

Agreed Value ($) of all Additional Vehicles

Ownership status of all Additional Vehicles (i.e., leased, financed, owned outright)

Modification Type of all Additional Vehicles (i.e., stock, high performance, modified/custom, replica/kit/reconstructed)

Garage or Storage Type for all Additional Vehicles

For example: a locked private garage, an open carport, outdoor driveway, storage unit, climate-controlled facility, outdoors with cover.

Registration type of all Additional Vehicles (i.e., historical, non-historical, not registered)

Are all Additional Vehicles registered solely to the named insured(s) provided in Step 1 of this form?

Yes

Please provide the Registrant and Title Holder (if owned) for all Additional Vehicles.

Other Household Vehicles

Do you own other vehicle(s) as "daily driver(s)"?

Yes

Please be advised, a classic or antique auto insurance policy is not intended to insure your primary vehicle.

Are all other household vehicles currently insured under a separate policy?

Yes

Other Information

Has any listed driver had an auto insurance claims in the past 5 years?

Yes

Please provide claim details (i.e., date, total cost and description)

Has any listed driver had a ticket or violation in the past 5 years?

Yes

Please provide claim details (i.e., date and description)

Are any vehicle(s) used for commuting to work/school or for business purposes?

Yes

Please describe the type of work and with which vehicle(s)

Are any vehicles used to drive for Uber, GrubHub or any other ride share or delivery service?

Yes

Please describe the type of service and with which vehicle(s)

Do any vehicle(s) have existing damage?

Yes

Please describe the existing damage and indicate which vehicle(s)

Are you interested in obtaining quotes for any other type of insurance?

Yes

What other types of insurance are you interested in?

Home Insurance

Primary Auto Insurance

Personal Umbrella Insurance

Commercial Insurance

Other Insurance

What other types of insurance are you interested in?

Current Insurance Information

Do you currently have auto insurance?

Yes

Please Upload a Copy of your Current Auto Insurance Policy Declarations or Send a Copy to info@brcinsurance.com

Max. file size: 3 MB.

We must receive a copy of your current auto insurance policy declarations if you are currently insured. We will leverage your policy documents for important information regarding your vehicles, coverages, endorsements, credits and more.

What is the reason for not currently having auto insurance?

Please provide a reason for not currently having auto insurance.

If there is anything else you'd like to share with us, please do so below. If nothing, please leave blank and select submit.

**Important: Please note completion of any request(s) for information does not constitute the purchase of insurance. No coverage may be added, changed or bound as a result of submitting a request for information or quotation of insurance. All coverage must be confirmed by the agency in writing subject to an acceptable signed application meeting the underwriting guidelines of the Insurance Company.