"Your Insurance Resource Center"
 





(631) 207-5400



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CALL US
(631) 207-5400

FAX US
(631) 207-5401

E-MAIL US
info@centennialagency.com




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REPLACE A VEHICLE

Please complete the information below to replace
a vehicle on your current auto policy

Contact Information
 
Current Auto Policy Number:
 
Name on Policy:
 
Your Name:
 
Email Address:
 
Daytime Telephone Number:
Vehicle Being Replaced:
 
Old Vehicle Make:
 
Old Vehicle Model:
 
Old Vehicle Year:
NEW VEHICLE INFORMATION
 
Effective Date of Policy Change:
(mm/dd/year)
 
VIN #:
 
Year of New Vehicle:
 
Make of New Vehicle:
 
Model of New Vehicle:
 
Is this a purchase or lease:

 
Body Type of New Vehicle:
 
Title Holder/Registered Owner:
 
Name of Principal Driver:
 
Principal Driver's Relationship to Named Insured:
 
Occasional Driver/Operator:
 
Purchase Price:
 
Lien Holder/Loss Payee Name:
 
Lien Holder Address:
 
Garage Address:
New Vehicle Desired Coverages:
 
Vehicle Useage:
(describe)
 
Miles to work (one way):
 
Deductibles:
Comprehensive
 
 
Collision
 
Anti-Lock Brakes:
 
Car Alarm:
 
Air Bags:
 
Rental Coverage:
 
Towing Coverage:
 
Additional Comments:
Please Note: Insurance coverage cannot be bound without a written binder from our office.
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"Your Insurance Resource Center"

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(631) 207-5400
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