AUTO PURCHASE NOTIFICATION FORM

PERSONAL INSURANCE

LEGACY PROGRAM

GROUP EXCESS

OTHER COVERAGES

VALUABLE ARTICLES PURCHASE
FORM

AUTO PURCHASE NOTIFICATION
FORM

TIP OF THE MONTH

WHO WE ARE

BWD ASSURANCES NEWSLETTER

To notify us of the purchase of an automobile, please complete this information below. The automobile is not covered until you have been notified by BWD that your coverage has become effective.

* Required Fields


Current Automobile - skip if not applicable
Are we deleting any vehicle on the policy now?	Yes No
Year
Make
Model
Are Your Plates Being Transferred?	Yes No


New Automobile Information
Effective Date	*
Year	*
Make	*
Model	*
VIN Number	*
Vehicle Registered to	*
Loss Payee/Additional Insured
Cost of New Vehicle	*


Credits
Passive Restraints	Yes No
Day Time Running Lights	Yes No
Number of Airbags	1 2 4 6
Anti-Lock Brakes	Yes No
Anti-Theft Device	Yes No
VIN Etching	Yes No


ID Card - Mailing Address
First Name	*
Last Name	*
Address	*
City	*
State	*
Zip	*
Email	*
Phone	*
Fax

"Multiple Series Limited Liability Company"