Pelling & Associates Insurance Brokers / Consultants - Hagerty Silver Wheel Plan On-Line Application

Hagerty Silver Wheel Plan
On-Line Application

Plan Choice (Please Check)
	Coverage for non-modified vehicles used for hobby and/or collector car activities, and not used for regular transportation, in two Categories: Antique & Classic for automobiles 25 years and older, and Special Interest for automobiles 15 to 24 years old.
	Coverage for Modified, Street Rod & Custom vehicles used for hobby and/or collector car activities, and not used for regular transportation, which are 15 years old or older.

Applicant Information
Applicant
Address
City/Town
Province
Postal Code
Telephone (Home)
Telephone (Office)
Fax
Cell
E-mail

Principle Drivers Information
Drivers Licence Number
Date of Birth (DD/MMM/YYYY)
Years of Driving Experience

Additional Drivers Information
Drivers Licence Number
Date of Birth (DD/MMM/YYYY)
Years of Driving Experience

Your Daily Vehicle
Insurance Company For Daily Vehicle
Policy Number or Licence Plate Number
Expiry Date

Insurance Information For Your Collector Vehicle
Previous Insurance Company
Policy Number or Licence Plate Number
Expiry Date

List all Losses in the past 6 years (including Date, Cause & Amount Paid, if None state "NIL").
List all Traffic Convictions in the past 3 years (excluding parking tickets, if None state "NIL").

Collector Vehicle Information
Year
Make
Model
Serial Number
Insured Value

By checking here
I confirm that:

MY VEHICLES WILL BE CHIEFLY used for hobby and/or collector car activities. My Vehicle will not be used for regular transportation. (i.e., shopping, vacation, business, and to and from work). I have a daily vehicle insured under a separate policy. Insurance becomes effective on payment of premium, acceptance of risk and completion of full Application. All drivers must have 10 years minimum driving experience. A copy of your vehicle registration and coloured photos of each vehicle will be required. I am the registered owner and understand that an Application for insurance will be forwarded to me and that it must be signed and returned.

Please note that this is an application only, no insurance coverages will apply unless confirmation is issued by Pelling & Associates Insurance Brokers/Consultants Inc.