Mid-Columbia Insurance

Add Vehicle — Complete 1 form for each Additional Vehicle
If adding "other than collision' or 'collision' coverage the agency will require you email us 2 photos showing all 4 sides of the vehicle or stop by the office for photos to be taken. Photos may be emailed to:
Registered Owner Name:
Year:
Make:	--select-- Acura Alfa Romeo AM General American Motors ARO Audi Avanti Bertone BMW Buick Cadillac Checker Chevrolet Chrysler Daewoo Daihatsu Delorean Dodge Eagle Ferrari Fiat Ford Geo GMC Honda Hyundai Infiniti International Isuzu Jaguar Jeep Kia Lancia Land Rover Lexus Licoln Lotus Maserati Mazda Mercedes Benz Mercury Merkur MG Mitsubishi Nissan Oldsmobile Opel Plymouth Pontiac Porsche Renault Saab Saturn Sterling Subaru Suzuki Toyota Triumph TVR Volkswagen Volvo Yugo
Model:
Sub-Model (ie: LX, GTI):
*Vehicle Identification Number (VIN):
How many doors?	2 doors     4 doors
Convertible:	Yes     No
4x4:	Yes     No
Vehicle Usage:	--select-- Pleasure Work Business Artisan Farm
Miles to work one-way:
Other than Collision Deductible:	--select-- None 100 250 500 1000
Collision Deductible:	--select-- None 100 250 500 1000
Any damage to vehicle?	Yes**     No
Any special equipment?	Yes**     No
Vehicle modified or salvaged?	Yes**     No

* I understand that no changes will go into effect until I sign the change request that the agency will email me.

* Required Fields
** If answer is Yes please describe in Additional Information field