Add Vehicle to Policy

Personal Information

Name*

First Last

Address*

Street Address City State / Province / Region ZIP / Postal Code

Primary Phone*

Please enter number we can call should we have any questions about your request.

Email*

Policy Information

Information to help us serve you better and faster.

Policy Number*

Current Insurance Provider

Optional

Add Vehicle Information

The same coverages & deductibles will be applied to this vehicle at the highest limits currently on the policy

Are you replacing an existing vehicle with this one?*

Yes
No

Date Add to Policy will take Effect:*

Year*

Make*

Examples: Ford, Chrysler, Dodge, Toyota

Model*

Examples: Mustang, IS250, Edge

Ownership*

Lender Name

If known, please share. If not known, we will be in touch.

Lender Address

If known, please share. If not known, we will be in touch.

Street Address Address Line 2 City State ZIP Code

Lease Company

If known, please share. If not known, we will be in touch.

Lease Company Address

If known, please share. If not known, we will be in touch.

Street Address Address Line 2 City State ZIP Code

Vehicle Identification Number (VIN)

If known, please enter. If not known, we will be in touch.

ID Cards and/or Binders - How would you like them delivered?*

Email
Fax
Pick-up at our Office
Mail to Policy Mailing Address

Contact Name*

Contact Email*

Fax Number*

Keating Agency Insurance
West Hartford Center
10 Arapahoe Road
West Hartford, CT 06017

Remove Vehicle Information

Is the Remove Vehicle Date different from the Add Vehicle Date?*

Yes
No

Date Remove will take Effect:*

Year*

Make*

Examples: Ford, Chrysler, Dodge, Toyota

Model*

Examples: Mustang, IS250, Edge

Dispose Reason*

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Security

Liberty Mutual

The Hartford

Travelers

Kemper

Quincy Mutual Group

Nat Gen Premier

Progressive

Safeco

Mapfre

The Main Street America Group

Nationwide

Chubb

Union Mutual

Plymouth Assurance

Foremost

American Modern

Guard

Personal Information

Policy Information

Add Vehicle Information

Remove Vehicle Information

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