"*" indicates required fields Name* First Last Email Address* Phone Number*Zip Code*Policy Number*Effective Date* MM slash DD slash YYYY # Vehicles To AddPlease enter a number from 1 to 5.Vehicle 1Purchase Date* MM slash DD slash YYYY Vehicle Year*Please enter a number from 1900 to 2050.Vehicle Make*Vehicle Model*Vehicle VIN*Primary Driver*Current Odometer*One Way Commute Distance*Estimated Yearly Mileage*Ownership*Select from Drop DownOwnedLeasedFinancedLienLoanOtherPrimary Use*Select from Drop DownBusinessFarmingPleasureTo/From WorkTo/From SchoolAnti Theft Features*Select All That ApplyNoneAlarmVehicle Recovery SystemVIN EtchingOtherPassive Restraints*Select All That ApplyNoneAutomatic Seat BeltsDriver Side AirbagPassenger AirbagSide Curtain AirbagOtherAnti-Lock Brakes*Select from Drop DownYesNoDaytime Running Lights*Select from Drop DownYesNoPrior Damage to Vehicle*Select from Drop DownYesNoVehicle Ever Used for Deliveries*Select from Drop DownYesNoComprehensive Deductible*Select from Drop DownNo Coverage0501002002505001000Collision Deductible*Select from Drop DownNo Coverage0501002002505001000Full Glass Coverage*Select from Drop DownYesNoAgent Name (Optional)Vehicle 2Purchase Date* MM slash DD slash YYYY Vehicle Year*Please enter a number from 1900 to 2050.Vehicle Make*Vehicle Model*Vehicle VIN*Primary Driver*Current Odometer*One Way Commute Distance*Estimated Yearly Mileage*Ownership*Select from Drop DownOwnedLeasedFinancedLienLoanOtherPrimary Use*Select from Drop DownBusinessFarmingPleasureTo/From WorkTo/From SchoolAnti Theft Features*Select All That ApplyNoneAlarmVehicle Recovery SystemVIN EtchingOtherPassive Restraints*Select All That ApplyNoneAutomatic Seat BeltsDriver Side AirbagPassenger AirbagSide Curtain AirbagOtherAnti-Lock Brakes*Select from Drop DownYesNoDaytime Running Lights*Select from Drop DownYesNoPrior Damage to Vehicle*Select from Drop DownYesNoVehicle Ever Used for Deliveries*Select from Drop DownYesNoComprehensive Deductible*Select from Drop DownNo Coverage0501002002505001000Collision Deductible*Select from Drop DownNo Coverage0501002002505001000Full Glass Coverage*Select from Drop DownYesNoAgent Name (Optional)Vehicle 3Purchase Date* MM slash DD slash YYYY Vehicle Year*Please enter a number from 1900 to 2050.Vehicle Make*Vehicle Model*Vehicle VIN*Primary Driver*Current Odometer*One Way Commute Distance*Estimated Yearly Mileage*Ownership*Select from Drop DownOwnedLeasedFinancedLienLoanOtherPrimary Use*Select from Drop DownBusinessFarmingPleasureTo/From WorkTo/From SchoolAnti Theft Features*Select All That ApplyNoneAlarmVehicle Recovery SystemVIN EtchingOtherPassive Restraints*Select All That ApplyNoneAutomatic Seat BeltsDriver Side AirbagPassenger AirbagSide Curtain AirbagOtherAnti-Lock Brakes*Select from Drop DownYesNoDaytime Running Lights*Select from Drop DownYesNoPrior Damage to Vehicle*Select from Drop DownYesNoVehicle Ever Used for Deliveries*Select from Drop DownYesNoComprehensive Deductible*Select from Drop DownNo Coverage0501002002505001000Collision Deductible*Select from Drop DownNo Coverage0501002002505001000Full Glass Coverage*Select from Drop DownYesNoAgent Name (Optional)Vehicle 4Purchase Date* MM slash DD slash YYYY Vehicle Year*Please enter a number from 1900 to 2050.Vehicle Make*Vehicle Model*Vehicle VIN*Primary Driver*Current Odometer*One Way Commute Distance*Estimated Yearly Mileage*Ownership*Select from Drop DownOwnedLeasedFinancedLienLoanOtherPrimary Use*Select from Drop DownBusinessFarmingPleasureTo/From WorkTo/From SchoolAnti Theft Features*Select All That ApplyNoneAlarmVehicle Recovery SystemVIN EtchingOtherPassive Restraints*Select All That ApplyNoneAutomatic Seat BeltsDriver Side AirbagPassenger AirbagSide Curtain AirbagOtherAnti-Lock Brakes*Select from Drop DownYesNoDaytime Running Lights*Select from Drop DownYesNoPrior Damage to Vehicle*Select from Drop DownYesNoVehicle Ever Used for Deliveries*Select from Drop DownYesNoCollision Deductible*Select from Drop DownNo Coverage0501002002505001000Comprehensive Deductible*Select from Drop DownNo Coverage0501002002505001000Full Glass Coverage*Select from Drop DownYesNoAgent Name (Optional)Vehicle 5Purchase Date* MM slash DD slash YYYY Vehicle Year*Please enter a number from 1900 to 2050.Vehicle Make*Vehicle Model*Vehicle VIN*Primary Driver*Current Odometer*One Way Commute Distance*Estimated Yearly Mileage*Ownership*Select from Drop DownOwnedLeasedFinancedLienLoanOtherPrimary Use*Select from Drop DownBusinessFarmingPleasureTo/From WorkTo/From SchoolAnti Theft Features*Select from Drop DownNoneAlarmVehicle Recovery SystemVIN EtchingOtherPassive Restraints*Select from Drop DownNoneAutomatic Seat BeltsDriver Side AirbagPassenger AirbagSide Curtain AirbagOtherAnti-Lock Brakes*Select from Drop DownYesNoDaytime Running Lights*Select from Drop DownYesNoPrior Damage to Vehicle*Select from Drop DownYesNoVehicle Ever Used for Deliveries*Select from Drop DownYesNoCollision Deductible*Select from Drop DownNo Coverage0501002002505001000Comprehensive Deductible*Select from Drop DownNo Coverage0501002002505001000Full Glass Coverage*Select from Drop DownYesNoAgent Name (Optional)Important noticeSubmitting this form does not bind coverage or make changes to your policy. No coverage, change, addition, or deletion will be effective until confirmed in writing by a licensed Galloway Insurance agent or your insurance company. Please contact our office to confirm any updates.
