Sheaner Insurance Agency
Herbert M. Sheaner, Jr. 

Tell us your Name and Policy Number.

Tell us about the vehicle you want to add.

Garaging street address if other than address above
City
State	Texas
Zip code
County

 

Vehicle	Describe in comments how vehicle is used.
*Year
*Make (Manufacturer)
*Model
*Doors	(choose one) 2 4 5
*Cost new $
*Vehicle Identification Number
*4x4	(choose one) Yes No
*Anti-theft device	(choose one) Yes No
*Use	(choose one) Commercial Service - used to visit no more than 3 job sites per day Delivery - used to deliver goods to residential dwellings Private Passenger vehicle driven to and from work
*Radius of Operation	(choose one) 0-50 miles 51-100 miles 101-200 miles more than 200 miles
*Gross Vehicle Weight	(choose one) 0-10,000 lbs 10,001-20,000 lbs 20,001-45,000 lbs Over 45,000 lbs (combine weight of vehicle + carrying capacity
*Passenger restraint	(choose one) Automatic seat belts Manual seat belts
*Air bags	(choose one) None Driver's side only Driver and passenger sides

Tell us date this change should take effect.

*Effective Date (mm-dd-yr)

Tell us about additional driver(s) for this vehicle, if any.

*Driver 1	No additional drivers to be added at this time Yes - Add the following Drivers
First name
Last name
Age
Gender	(choose one) Male Female
Marital status	(choose one) Married Single Divorced Separated
Defensive driving certification within last 3 years	(choose one) Yes No
Number of Years with a  Texas Drivers license	more than 3 years 2 years 1 year less than one year

Driver 2
First name
Last name
Age
Gender	(choose one) Male Female
Marital status	(choose one) Married Single Divorced Separated
Defensive driving certification within last 3 years	(choose one) Yes No
Number of Years with a  Texas Drivers license	more than 3 years 2 years 1 year less than one year

Have any of the above drivers had any traffic violations or accidents (regardless of fault) in the last 3 years?

(choose one) Yes No

If you answered "Yes," please describe below.

Tell us about the coverage you want.

*Limit of liability $	Same as currently provided on policy 20/40/15 25/50/25 50/100/50 100/300/100 250/500/100
*Personal injury protection $	Same as currently provided on policy No coverage 2,500 5,000 10,000
*Uninsured/underinsured motorist $	Same as currently provided on policy No coverage 20/40/15 25/50/25 50/100/50 100/300/100 250/500/100
*Comprehensive deductible $	(choose one) No coverage 50 100 200 250 500 1,000
*Collision deductible $	(choose one) No coverage 250 500 1,000

Please provide any additional information or comments.