Secured by SSL

Add Vehicle to Existing Policy


Fill out the following form as completely as possible. Once you have completed the form, click the Submit button to send your information. Your request will be handled promptly.

All of our forms use a secure connection using 128-bit SSL encryption.  Rest assured your information is secure.


Personal Information
First Name
Required
Last Name
Required
Street
Required
City
Required
State
Required
ZIP / Postal Code
Required
Primary Phone Number
Required
Alternate Phone Number
Optional
E-Mail Address
Required
Policy Information
Policy Number
Required
Vehicle Information
Vehicle One
Vehicle #1
Optional


Vehicle 1 - How many days per week do you commute?
Optional
Vehicle 1 - Average Commute in Miles
Optional
Vehicle 1 - Collision Deductible
Optional
Vehicle 1 - Comprehensive Deductible
Optional
Vehicle 1 - Towing
Optional
Vehicle 1 VIN
Optional
Vehicle 1- Rental
Optional
Vehicle Two
Vehicle #2
Optional


Vehicle 2 - How many days per week do you commute?
Optional
Vehicle 2 - Average Commute in Miles
Optional
Vehicle 2 - Collision Deductible
Optional
Vehicle 2 - Comprehensive Deductible
Optional
Vehicle 2 - Towing
Optional
Vehicle 2 VIN
Optional
Vehicle 2- Rental
Optional
Vehicle Three
Vehicle #3
Optional


Vehicle 3 - How many days per week do you commute?
Optional
Vehicle 3 - Average Commute in Miles
Optional
Vehicle 3 - Collision Deductible
Optional
Vehicle 3 - Comprehensive Deductible
Optional
Vehicle 3 - Towing
Optional
Vehicle 3 VIN
Optional
Vehicle 3- Rental
Optional
Vehicle Four
Vehicle #4
Optional


Vehicle 4 - How many days per week do you commute?
Optional
Vehicle 4 - Average Commute in Miles
Optional
Vehicle 4 - Collision Deductible
Optional
Vehicle 4 - Comprehensive Deductible
Optional
Vehicle 4 - Towing
Optional
Vehicle 4 VIN
Optional
Vehicle 4- Rental
Optional
Submission Validation
Required
CAPTCHA
Change the CAPTCHA codeSpeak the CAPTCHA code
 
Enter the Validation Code from above.
Important Notice
Any submissions or payments made via this website do not constitute a binding agreement to your policy or coverages. Changes and payments to policies are not effective or binding until you, or any party involved, receive official notice from either your insurance agent, or your insurance company. If you have any questions, please feel free to contact us.

Per the terms of our online privacy policy we will not resell your information to any third-party.

           609 W Lincoln Ave, Goshen, IN 46526    (800) 437-5860      Copyright © 2017 Salem Insurance