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		Add Vehicle Policyholder Name First M.I. Last Insurance Provider Select Partner Allied Arrowhead Encompass Hartford Mercury Pacific Specialty Progressive Safeco Travelers Policy No. Vehicle Information Year (YYYY) Make Model VIN Purchase Date MM DD YY Purchase Price Odometer Reading Ownership Registered Owner Name: First M.I. Last Financed: If your current policy does not include comprehensive & collision coverage, please visit the "update Coverage" section of our website to select your comprehensive and collision deductibles or contact one of our insurance representatives for assistance. Leased: If your current liability limits are not $100,000/$300.000, please update your liability limits by visiting the "Update Coverage" section of our website. Owned: Lienholder/Lessor Information Lienholder/Lessor Address or PO Box Vehicle Use Commute (Work/School) Business Commercial Pleasure Miles for one-way commute to school or work Miles Driven Annual Miles Driven Is this vehicle replacing an existing vehicle on your policy?   Yes: No: If Yes, please complete the following for the vehicle to be replaced Year Make Model       Get the United Advantage Insurance products are available through United Agencies and it's affiliates including UIP Insurance Services, LLC. California Insurance License No.0252636. 2 0 1 0   U I P   I n s u r a n c e   S e r v i c e s ,   L L C.  •  L i c e n s e   N o.  0 2 5 2 6 3 6  •   P r i v a c y   P o l i c y