Add or Replace Vehicle Request from PA Insurance Rates.com

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Questions?
Ask the
Agent!

E-mail Questions to: jrumer@rumergroup.com

Toll-Free: 1-888-81-RUMER
Phone: 1-215-918-1882
Fax: 1-215-918-2220

Office Located at:
1432 Easton Road, #3-I
Warrington, PA 18976

Please Add/Delete Vehicle From Our Personal Auto Insurance Per Below: One Simple Form - takes only 2-3 Minutes! Your Personal Data
Your Name (First, Last)

E-Mail (REQUIRED):

E-Mail (again to verify accuracy):

Phone (REQUIRED):

Your Policy Number: (REQUIRED)

Vehicle Details

Effective Date of Change:

Are You Adding, Replacing, or Deleting Vehicle?	Adding Vehicle Replacing Vehicle Deleting Vehicle

Year, Make, Model You Are Adding:	Year: Make: Model:

(Year, Make, Model You Are Removing, if any):

New Vehicle's Identification #:

New Vehicle's Primary Driver Will Be:

New Vehicle's Primary Titleholder is:

How far will this vehicle be driven to work or school?:	Miles

Answer yes or no:
Antilock brakes?	Yes No

Vehicle Alarm?	Yes No

Air Bags?	Yes No

Do You want Collision coverage?	Yes No
If yes, list desired deductible:	Deductible

Do You want Comprehensive (other than collision) coverage?	Yes No
If yes, list desired deductible:	Deductible

Do You want Rental coverage?	Yes No

Do You want Lease or loan coverage?	Yes No

Is there a loss payee, lease company, or bank loan on this car?	Yes No

If yes, list bank's name, address, and loan number here:

Is the garaging address for this vehicle the same as your current home address? (if not, list garaging address in remarks below)	Yes No

Any comments or special instructions?

If we need further information, how should we contact you?	Fax E-Mail Regular Mail Please Call Me!

Thank you for filling out this form COMPLETELY!
We deem your data submitted as PRIVATE information. Every step has been taken to insure your privacy, security, and to release this information only to you. By checking the box below you agree to allow our agency to release this information via the method you have chosen, and to release them from any liability should this information be accidentally viewed by others. Also, the insurance carriers reserve the right to issue coverage or not, and we cannot guarantee acceptance of a risk until approved by the company.
Yes, Please Make the Vehicle Changes above. I understand that none of the changes requested are in force until written confirmation is received from the Rumer Insurance and Financial Group.

Click Button Below When Done

Please Click Only Once . . . May take up to 30 seconds!


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