Phalanx Industry Corporation

Transportation

Property

Life and Health

Commercial

Annuitys

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Add a Vehicle
Current Auto Policy Number:
First Name:
Last Name:
Address:
City:
State:
Zip Code:
Home Phone:
Work Phone:
Cell Phone:
Email:
Best time to call:
Preferred Contact Method:
Effective Date of Policy Change:
Vehicle Identification Number (VIN):
Year of Vehicle:
Make of Vehicle:
Model of Vehicle:
Body Type of Vehicle (Sedan, SUV etc):
Name of Principle Driver:
Principle Driver relationship to Policy Holder:
Name of Occasional Driver:
Is this a purchase or a lease?	Purcase Lease
Purchase Price:
Lien Holder/Loss Payee Name:
Lien Holder Address:
Garage Address:
Vehicle Usage (please describe):
Miles to Work (One Way):
Comprehensive Deductible:
Collision Deductible:
Anti-Lock Brakes?	Yes No
Car Alarm:	Yes No
Air Bags:	Yes No
Rental Coverage:	Yes No
Towing Coverage:	Yes No