Wells & Associates Insurance Agency
Contact Us
Call Us Today 863-465-7155
Request A Quote   Contact Us
Menu
  • Home
  • About
  • Personal
    • Auto Insurance
    • Boat & Watercraft
    • Condo Insurance
    • Flood Insurance
    • Homeowners Insurance
    • Individual Annuities
    • Individual Disability
    • Individual Health Insurance
    • Individual Life Insurance
    • Long Term Care
    • Manufactured / Mobile Home
    • Motorcycle Insurance
    • Recreational Vehicle
    • Renters Insurance
  • Business
    • Church Insurance
    • Commercial Auto
    • Commercial Property
    • Contractors
    • Crop Insurance
    • Cyber Liability
    • Directors & Officers
    • Errors and Omissions
    • Farm & Ranch
    • General Liability
    • Group Health Insurance
    • Group Life Insurance
    • Professional Liability
    • Restaurant
    • Workers Compensation
    • Inland Marine Insurance
  • Quote Request
    • Auto Insurance
    • Boat & Watercraft
    • Church Insurance
    • Commercial Auto
    • Commercial Property
    • Condo Insurance
    • Contractors
    • Crop Insurance
    • Cyber Liability
    • Directors & Officers
    • Errors and Omissions
    • Farm & Ranch
    • Flood Insurance
    • General Liability
    • Group Health Insurance
    • Group Life Insurance
    • Homeowners Insurance
    • Individual Annuities
    • Individual Disability
    • Individual Health Insurance
    • Individual Life Insurance
    • Jewelry Floaters
    • Long Term Care
    • Manufactured / Mobile Home
    • Motorcycle Insurance
    • Professional Liability
    • Recreational Vehicle
    • Renters Insurance
    • Restaurant
    • Workers Compensation
  • Support
    • Payments & Claims
    • Add a Vehicle Form
    • Auto ID Card Request
    • Change of Address Form
    • Online Claim Form
    • Policy Change Request
    • Remove Vehicle Form
  • Resources
    • Mobile Responsive Version
    • Our Companies
    • Blog
    • Helpful Links
    • Common Insurance Terms
    • Privacy Policy Statement
    • Site Map
    • Refer a Friend
    • Testimonials
  • Contact
    • Lake Placid Office
    • Sebring Office
  • Facebook Facebook
  • Google Places Google Places
  • Blog Blog
  • Home Page
  • Secure Form

Secure Add a Vehicle Request Form

 
Your Name:
First Last

Policy Information

Policy Number:

Vehicle Information

Vehicle 1

Vehicle 1 Year:
Vehicle 1 Make:
Vehicle 1 Model:
Vehicle 1 VIN:
Primary Driver:
Current Odometer:
Estimated Yearly Mileage:
Ownership:
Primary Use:
Anti Theft Features:
Passive Restraints:
Anti-Lock Brakes:
Daytime Running Lights:
Any Prior Damage to Vehicle?
Vehicle Ever Used for Deliveries?
Comprehensive Deductible:
Collision Deductible:
Full Glass Coverage?

Vehicle 2

Vehicle 2 Year:
Vehicle 2 Make:
Vehicle 2 Model:
Vehicle 2 VIN:
Primary Driver:
Current Odometer:
Estimated Yearly Mileage:
Ownership:
Primary Use:
Anti Theft Features:
Passive Restraints:
Anti-Lock Brakes:
Daytime Running Lights:
Any Prior Damage to Vehicle?
Vehicle Ever Used for Deliveries?
Comprehensive Deductible:
Collision Deductible:
Full Glass Coverage?

Vehicle 3

Vehicle 3 Year:
Vehicle 3 Make:
Vehicle 3 Model:
Vehicle 3 VIN:
Primary Driver:
Current Odometer:
Estimated Yearly Mileage:
Ownership:
Primary Use:
Anti Theft Features:
Passive Restraints:
Anti-Lock Brakes:
Daytime Running Lights:
Any Prior Damage to Vehicle?
Vehicle Ever Used for Deliveries?
Comprehensive Deductible:
Collision Deductible:
Full Glass Coverage?

Vehicle 4

Vehicle 4 Year:
Vehicle 4 Make:
Vehicle 4 Model:
Vehicle 4 VIN:
Primary Driver:
Current Odometer:
Estimated Yearly Mileage:
Ownership:
Primary Use:
Anti Theft Features:
Passive Restraints:
Anti-Lock Brakes:
Daytime Running Lights:
Any Prior Damage to Vehicle?
Vehicle Ever Used for Deliveries?
Comprehensive Deductible:
Collision Deductible:
Full Glass Coverage?

Vehicle 5

Vehicle 5 Year:
Vehicle 5 Make:
Vehicle 5 Model:
Vehicle 5 VIN:
Primary Driver:
Current Odometer:
Estimated Yearly Mileage:
Ownership:
Primary Use:
Anti Theft Features:
Passive Restraints:
Anti-Lock Brakes:
Daytime Running Lights:
Any Prior Damage to Vehicle?
Vehicle Ever Used for Deliveries?
Comprehensive Deductible:
Collision Deductible:
Full Glass Coverage?

Remove Vehicle Option

Vehicle 1

Vehicle 1 Year:
Vehicle 1 Make:
Vehicle 1 Model:
Vehicle 1 VIN:

Vehicle 2

Vehicle 2 Year:
Vehicle 2 Make:
Vehicle 2 Model:
Vehicle 2 VIN:

Vehicle 3

Vehicle 3 Year:
Vehicle 3 Make:
Vehicle 3 Model:
Vehicle 3 VIN:

Vehicle 4

Vehicle 4 Year:
Vehicle 4 Make:
Vehicle 4 Model:
Vehicle 4 VIN:

Vehicle 5

Vehicle 5 Year:
Vehicle 5 Make:
Vehicle 5 Model:
Vehicle 5 VIN:
Website Disclaimer - Review Carefully:

This information is not an offer to sell insurance. Insurance coverage cannot be bound or changed via submission of this online form/application, e-mail, voice mail or facsimile. No binder, insurance policy, change, addition, and/or deletion to insurance coverage goes into effect unless and until confirmed directly with a licensed agent. Note any proposal of insurance we may present to you will be based upon the values developed and exposures to loss disclosed to us on this online form/application and/or in communications with us. All coverages are subject to the terms, conditions and exclusions of the actual policy issued. Not all policies or coverages are available in every state. You also agree to release us from any liability if this information is accidentally viewed by unauthorized persons. We will only use this information for insurance quoting purposes and not distribute to other parties.
  • Navigation
  • Home
  • About
  • Quote Request
  • Support
  • Resources
  • Payments & Claims
  • Our Companies
  • Blog
  • Contact
  • Privacy Policy Statement
  • Personal Lines
  • Auto Insurance
  • Homeowners Insurance
  • Boat & Watercraft
  • Flood Insurance
  • Motorcycle Insurance
  • Individual Health Insurance
  • Individual Life Insurance
  • Recreational Vehicle
  • Renters Insurance
  • Condo Insurance
  • Commercial Lines
  • Business Owners Policy (BOP)
  • Commercial Auto
  • Commercial Property
  • Workers Compensation
  • General Liability
  • Bonds
  • Professional Liability
  • Restaurant
  • Church Insurance
  • Errors and Omissions
  • Quote Request Forms
  • Auto Insurance
  • Boat & Watercraft
  • Church Insurance
  • Commercial Auto
  • Commercial Property
  • Condo Insurance
  • Contractors
  • Crop Insurance
  • Cyber Liability
  • Directors & Officers
309 US Hwy 27 South Lake Placid, FL 33852 | Phone: 863-465-7155 | Fax: 863-699-1925| Contact Us | Get Map
4101 US Hwy 27 North Sebring, FL 33870| Phone: 863-382-3131 | Fax: 863-382-1334| Contact Us | Get Map
Located in Lake Placid, Florida; Sebring, Florida. - Licensed in Florida
Site by: AlicorSolutions.com • © 2019 Wells & Associates Insurance Agency