info@dickinsononline.com

(208) 773-0504
609 North Syringa Street, Post Falls, Idaho 83854

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Antique & Custom Auto Insurance Quote Request

Step 1 of 5

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Your Contact Information
Name*
First Last
Phone*
Email*
Address*
Address 1 Address 2 City State ZIP Code

Driver 1
Name*
First Last
Driver's License Number*
Driver's License State*
Date of Birth*
MM slash DD slash YYYY
How long have you had a driver's license?*
Your vehicle year, make and model.*
Driver 2
Name
First Last
Driver's License Number
Driver's License State
Date of Birth
MM slash DD slash YYYY
How long have you had a driver's license?
Your vehicle year, make and model.
Driver 3
Name
First Last
Driver's License Number
Driver's License State
Date of Birth
MM slash DD slash YYYY
How long have you had a driver's license?
Your vehicle year, make and model.
Driver 4
Name
First Last
Driver's License Number
Driver's License State
Date of Birth
MM slash DD slash YYYY
How long have you had a driver's license?
Your vehicle year, make and model.

Liability Coverage
Limit of Liability*
Apply Liability Coverage to all vehicles?*
- Yes
- No
If no, please indicate which vehicles to insure for Liability Coverage
Medical Payments Coverage
Medical Payments Limit*
- $1,000
- None
Apply Medical Payments Coverage to all vehicles?*
- Yes
- No
If no, please indicate which vehicles to insure for Medical Payments Coverage
Underinsured Motorists Coverage
Quote Underinsured Motorist Coverage equal to Liability limit?*
- Yes
- No
If no, please select a limit
Physical Damage Coverage
Include Physcial Damage Coverage?*
- Yes
- No
If yes, apply to all vehicles?
- Yes
- No
If Physical Damage Coverage is to be applied to only some vehicles, please indicate which ones.
Include Other than Physcial Damage Coverage (Comprehensive)*
- Yes
- No
If yes, apply to all vehicles?
- Yes
- No
If Other than Physical Damage Coverage is to be applied to only some vehicles, please indicate which ones

Have you or any driver in your household had any auto losses or moving violations in the past 3 years?*
- Yes
- No
If yes, please explain: include Date-Caust-Payment
Will you be using your antique/classic car as a means of daily transportation, errands or back-up?*
- Yes
- No
Do you belong to an automobile club?*
- Yes
- No
If yes, which club?
Has (will) the body, engine, or drive train of the antique/classic auto been (be) changed?*
- Yes
- No
If yes, please explain
Has the manufacturers horsepower for your auto been changed?*
- Yes
- No
If yes, please explain
Is any auto currently under restoration?*
- Yes
- No
If yes, what is the expected date of completion?
MM slash DD slash YYYY
If in shop, please list the name and address of shop.
Are all antique/classic auto(s) garaged?*
- Yes
- No
Construction of Garage
Is the location of the garage the same as the mailing address?
- Yes
- No
If no, please provide address(es)
What is the annual mileage for Club Functions?*
What is the annual mileage for Other Purposes?*
Please explain the Other Purposes use

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Please note, this is a request only. One of our agents will contact you to confirm the information you have provided.

Insurance Coverage can not be bound online or over the phone.

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The protection you need, at a price you can afford.

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Closed Saturday & Sunday

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609 N Syringa St
Post Falls, ID 83854

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(208) 773-0504
info@dickinsononline.com

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