Remove Vehicle Request Form

<!DOCTYPE html><html lang="en"><head><meta charset="utf-8"><meta http-equiv="X-UA-Compatible" content="IE=Edge" /><title>Remove Vehicle Request Form</title><meta name="viewport" content="width=device-width, initial-scale=1"><meta name="robots" content="noindex, nofollow"><meta name="description" content="Piedmont Oklahoma independent insurance agency offering auto, car, home, business, boat and recreational vehicle insurance."><base href="https://secureformsolutions.com/assets/paragonokc.com/"><link rel="stylesheet" href="https://maxcdn.bootstrapcdn.com/bootstrap/3.3.4/css/bootstrap.min.css"><link rel="stylesheet" href="https://maxcdn.bootstrapcdn.com/bootstrap/3.3.4/css/bootstrap-theme.min.css"><link rel="stylesheet" href="https://ajax.googleapis.com/ajax/libs/jqueryui/1.12.1/themes/smoothness/jquery-ui.css"><link rel="stylesheet" href="https://maxcdn.bootstrapcdn.com/font-awesome/4.6.2/css/font-awesome.min.css"><link href="https://fonts.googleapis.com/css?family=Yanone+Kaffeesatz:300,400" rel="stylesheet"><link rel="stylesheet" href="design/1810/style.php/style.scss"><link rel="icon" href="files/icon-144.png"><link rel="shortcut icon" href="files/favicon.ico"><link rel="apple-touch-icon" sizes="57x57" href="files/icon-57.png" /><link rel="apple-touch-icon" sizes="72x72" href="files/icon-72.png" /><link rel="apple-touch-icon" sizes="114x114" href="files/icon-114.png" /><link rel="apple-touch-icon" sizes="144x144" href="files/icon-144.png" /><meta name="twitter:card" content="summary" /><meta property="og:url" content="https://paragonokc.com/sfs"><meta property="og:title" content="Remove Vehicle Request Form"><meta property="og:description" content="Piedmont Oklahoma independent insurance agency offering auto, car, home, business, boat and recreational vehicle insurance."> <meta property="og:image" content="https://paragonokc.com/files/logo.png"> <meta name="thumbnail" content="https://paragonokc.com/files/logo.png" /> </head><body class="body-page body-full-width"><div id="skrollr-body"><div class="top-strip visible-xs"><div class="container">Call Us: <a href="tel:4052839250" class="phone-link">405-283-9250</a>  •  <a href="online-insurance-quotes">Request a Quote</a></div></div><div class="header-wrapper"><header class="masthead"><div class="container"><div class="row"><div class="col-xs-12 col-md-3 header-logo"><a href="https://paragonokc.com"><img src="files/logo.png" id="logo" alt="Paragon Insurance"></a></div><div class="col-xs-12 col-md-9"><div class="navbar navbar-default" role="navigation"><div class="container"><div class="navbar-header"><button type="button" class="navbar-toggle collapsed" data-toggle="collapse" data-target="#navigation" aria-expanded="false" aria-controls="navigation"><span class="sr-only">Toggle navigation</span><span class="icon-bar"></span><span class="icon-bar"></span><span class="icon-bar"></span></button><a class="navbar-brand visible-xs" href="#">Menu</a></div><div class="collapse navbar-collapse" id="navigation"><ul class="nav nav-justified navbar-nav"><li><a href="https://paragonokc.com/" target="_self" aria-label="Home">Home</a></li><li><a href="https://paragonokc.com/about" target="_self" aria-label="About">About</a></li><li class="dropdown drop-cols-2 hidden-sm"><a target="_self" href="https://paragonokc.com/personal-insurance" class="dropdown-toggle disabled" data-toggle="dropdown" role="button" aria-label="Personal">Personal <span class="caret"></span></a><ul class="dropdown-menu"><li><a target="_self" href="https://paragonokc.com/personal-insurance/atv-insurance" aria-label="ATV">ATV</a></li><li><a target="_self" href="https://paragonokc.com/personal-insurance/car-insurance" aria-label="Auto Insurance">Auto Insurance</a></li><li><a target="_self" href="https://paragonokc.com/personal-insurance/boat-insurance" aria-label="Boat & Watercraft">Boat & Watercraft</a></li><li><a target="_self" href="https://paragonokc.com/personal-insurance/condo-insurance" aria-label="Condo Insurance">Condo Insurance</a></li><li><a target="_self" href="https://paragonokc.com/personal-insurance/earthquake-insurance" aria-label="Earthquake">Earthquake</a></li><li><a target="_self" href="https://paragonokc.com/personal-insurance/flood-insurance" aria-label="Flood Insurance">Flood Insurance</a></li><li><a target="_self" href="https://paragonokc.com/personal-insurance/home-insurance" aria-label="Homeowners Insurance">Homeowners Insurance</a></li><li><a target="_self" href="https://paragonokc.com/personal-insurance/individual-life-insurance" aria-label="Individual Life Insurance">Individual Life Insurance</a></li><li><a target="_self" href="https://paragonokc.com/personal-insurance/mobile-home-insurance" aria-label="Manufactured / Mobile Home">Manufactured / Mobile Home</a></li><li><a target="_self" href="https://paragonokc.com/personal-insurance/rv-motorhome-insurance" aria-label="Motor Home">Motor Home</a></li><li><a target="_self" href="https://paragonokc.com/personal-insurance/motorcycle-insurance" aria-label="Motorcycle Insurance">Motorcycle Insurance</a></li><li><a target="_self" href="https://paragonokc.com/personal-insurance/umbrella-insurance" aria-label="Personal Umbrella">Personal Umbrella</a></li><li><a target="_self" href="https://paragonokc.com/personal-insurance/pet-insurance" aria-label="Pet Insurance">Pet Insurance</a></li><li><a target="_self" href="https://paragonokc.com/personal-insurance/recreational-vehicle-insurance" aria-label="Recreational Vehicle">Recreational Vehicle</a></li><li><a target="_self" href="https://paragonokc.com/personal-insurance/renters-insurance" aria-label="Renters Insurance">Renters Insurance</a></li><li><a target="_self" href="https://paragonokc.com/personal-insurance/collector-car-insurance" aria-label="Collector Car">Collector Car</a></li><li><a target="_self" href="https://paragonokc.com/personal-insurance/wedding-insurance" aria-label="Wedding Insurance">Wedding Insurance</a></li></ul></li><li class="dropdown drop-cols-3 hidden-sm"><a target="_self" href="https://paragonokc.com/business-insurance" class="dropdown-toggle disabled" data-toggle="dropdown" role="button" aria-label="Business">Business <span class="caret"></span></a><ul class="dropdown-menu"><li><a target="_self" href="https://paragonokc.com/business-insurance/agri-business" aria-label="Agribusiness">Agribusiness</a></li><li><a target="_self" href="https://paragonokc.com/business-insurance/apartment-building-insurance" aria-label="Apartment Building Owners">Apartment Building Owners</a></li><li><a target="_self" href="https://paragonokc.com/business-insurance/builders-risk-insurance" aria-label="Builders Risk">Builders Risk</a></li><li><a target="_self" href="https://paragonokc.com/business-insurance/business-owners-policy" aria-label="Business Owners Policy (BOP)">Business Owners Policy (BOP)</a></li><li><a target="_self" href="https://paragonokc.com/business-insurance/church-insurance" aria-label="Church Insurance">Church Insurance</a></li><li><a target="_self" href="https://paragonokc.com/business-insurance/commercial-auto-insurance" aria-label="Commercial Auto">Commercial Auto</a></li><li><a target="_self" href="https://paragonokc.com/business-insurance/commercial-property-insurance" aria-label="Commercial Property">Commercial Property</a></li><li><a target="_self" href="https://paragonokc.com/business-insurance/commercial-umbrella-insurance" aria-label="Commercial Umbrella">Commercial Umbrella</a></li><li><a target="_self" href="https://paragonokc.com/business-insurance/condo-assoc-owners-insurance" aria-label="Condo Association">Condo Association</a></li><li><a target="_self" href="https://paragonokc.com/business-insurance/contractors-insurance" aria-label="Contractors">Contractors</a></li><li><a target="_self" href="https://paragonokc.com/business-insurance/crop-insurance" aria-label="Crop Insurance">Crop Insurance</a></li><li><a target="_self" href="https://paragonokc.com/business-insurance/cyber-liability-insurance" aria-label="Cyber Liability">Cyber Liability</a></li><li><a target="_self" href="https://paragonokc.com/business-insurance/directors-officers-insurance" aria-label="Directors & Officers">Directors & Officers</a></li><li><a target="_self" href="https://paragonokc.com/business-insurance/errors-omissions-insurance" aria-label="Errors and Omissions">Errors and Omissions</a></li><li><a target="_self" href="https://paragonokc.com/business-insurance/farm-insurance" aria-label="Farm & Ranch">Farm & Ranch</a></li><li><a target="_self" href="https://paragonokc.com/business-insurance/liability-insurance" aria-label="General Liability">General Liability</a></li><li><a target="_self" href="https://paragonokc.com/business-insurance/group-life-insurance" aria-label="Group Life Insurance">Group Life Insurance</a></li><li><a target="_self" href="https://paragonokc.com/business-insurance/landlord-insurance" aria-label="Landlord Insurance">Landlord Insurance</a></li><li><a target="_self" href="https://paragonokc.com/business-insurance/oil-gas" aria-label="Oil / Gas Operators">Oil / Gas Operators</a></li><li><a target="_self" href="https://paragonokc.com/business-insurance/professional-liability-insurance" aria-label="Professional Liability">Professional Liability</a></li><li><a target="_self" href="https://paragonokc.com/business-insurance/restaurant-insurance" aria-label="Restaurant">Restaurant</a></li><li><a target="_self" href="https://paragonokc.com/business-insurance/trucking-insurance" aria-label="Truck & Trucking">Truck & Trucking</a></li><li><a target="_self" href="https://paragonokc.com/business-insurance/workers-comp-insurance" aria-label="Workers Compensation">Workers Compensation</a></li><li><a target="_self" href="https://paragonokc.com/business-insurance/special-event-insurance" aria-label="Special Event Insurance">Special Event Insurance</a></li><li><a target="_self" href="https://paragonokc.com/business-insurance/hotel-insurance" aria-label="Hotel / Motel">Hotel / Motel</a></li></ul></li><li class="dropdown drop-cols-3"><a target="_self" href="https://paragonokc.com/online-insurance-quotes" class="dropdown-toggle disabled" data-toggle="dropdown" role="button" aria-label="Quote Request">Quote Request <span class="caret"></span></a><ul class="dropdown-menu"><li><a target="_self" href="https://secureformsolutions.com/form/paragonokc.com/apartmentowners" aria-label="Apartment Building Owners">Apartment Building Owners</a></li><li><a target="_self" href="https://secureformsolutions.com/form/paragonokc.com/boat" aria-label="Boat & Watercraft">Boat & Watercraft</a></li><li><a target="_self" href="https://secureformsolutions.com/form/paragonokc.com/bonds" aria-label="Bonds">Bonds</a></li><li><a target="_self" href="https://secureformsolutions.com/form/paragonokc.com/builders_risk" aria-label="Builders Risk">Builders Risk</a></li><li><a target="_self" href="https://secureformsolutions.com/form/paragonokc.com/business" aria-label="Business Owners Policy (BOP)">Business Owners Policy (BOP)</a></li><li><a target="_self" href="https://secureformsolutions.com/form/paragonokc.com/church" aria-label="Church Insurance">Church Insurance</a></li><li><a target="_self" href="https://secureformsolutions.com/form/paragonokc.com/commauto" aria-label="Commercial Auto">Commercial Auto</a></li><li><a target="_self" href="https://secureformsolutions.com/form/paragonokc.com/comm_building" aria-label="Commercial Property">Commercial Property</a></li><li><a target="_self" href="https://secureformsolutions.com/form/paragonokc.com/condo" aria-label="Condo Association">Condo Association</a></li><li><a target="_self" href="https://secureformsolutions.com/form/paragonokc.com/condominium" aria-label="Condo Insurance">Condo Insurance</a></li><li><a target="_self" href="https://secureformsolutions.com/form/paragonokc.com/contractors" aria-label="Contractors">Contractors</a></li><li><a target="_self" href="https://secureformsolutions.com/form/paragonokc.com/crop" aria-label="Crop Insurance">Crop Insurance</a></li><li><a target="_self" href="https://secureformsolutions.com/form/paragonokc.com/cyberliability" aria-label="Cyber Liability">Cyber Liability</a></li><li><a target="_self" href="https://secureformsolutions.com/form/paragonokc.com/dando" aria-label="Directors & Officers">Directors & Officers</a></li><li><a target="_self" href="https://secureformsolutions.com/form/paragonokc.com/earthquake" aria-label="Earthquake">Earthquake</a></li><li><a target="_self" href="https://secureformsolutions.com/form/paragonokc.com/eando" aria-label="Errors and Omissions">Errors and Omissions</a></li><li><a target="_self" href="https://secureformsolutions.com/form/paragonokc.com/farm" aria-label="Farm & Ranch">Farm & Ranch</a></li><li><a target="_self" href="https://secureformsolutions.com/form/paragonokc.com/flood" aria-label="Flood Insurance">Flood Insurance</a></li><li><a target="_self" href="https://secureformsolutions.com/form/paragonokc.com/general" aria-label="General Interest">General Interest</a></li><li><a target="_self" href="https://secureformsolutions.com/form/paragonokc.com/liability" aria-label="General Liability">General Liability</a></li><li><a target="_self" href="https://secureformsolutions.com/form/paragonokc.com/grouplife" aria-label="Group Life Insurance">Group Life Insurance</a></li><li><a target="_self" href="https://secureformsolutions.com/form/paragonokc.com/homeowners" aria-label="Homeowners Insurance">Homeowners Insurance</a></li><li><a target="_self" href="https://secureformsolutions.com/form/paragonokc.com/life" aria-label="Individual Life Insurance">Individual Life Insurance</a></li><li><a target="_self" href="https://secureformsolutions.com/form/paragonokc.com/jewelry" aria-label="Jewelry Floaters">Jewelry Floaters</a></li><li><a target="_self" href="https://secureformsolutions.com/form/paragonokc.com/mobilehome" aria-label="Manufactured / Mobile Home">Manufactured / Mobile Home</a></li><li><a target="_self" href="https://secureformsolutions.com/form/paragonokc.com/motorcycle" aria-label="Motorcycle Insurance">Motorcycle Insurance</a></li><li><a target="_self" href="https://secureformsolutions.com/form/paragonokc.com/oil" aria-label="Oil / Gas Operators">Oil / Gas Operators</a></li><li><a target="_self" href="https://secureformsolutions.com/form/paragonokc.com/umbrella" aria-label="Personal Umbrella">Personal Umbrella</a></li><li><a target="_self" href="https://secureformsolutions.com/form/paragonokc.com/general" aria-label="Pet Insurance">Pet Insurance</a></li><li><a target="_self" href="https://secureformsolutions.com/form/paragonokc.com/profliability" aria-label="Professional Liability">Professional Liability</a></li><li><a target="_self" href="https://secureformsolutions.com/form/paragonokc.com/rv" aria-label="Recreational Vehicle">Recreational Vehicle</a></li><li><a target="_self" href="https://secureformsolutions.com/form/paragonokc.com/renters" aria-label="Renters Insurance">Renters Insurance</a></li><li><a target="_self" href="https://secureformsolutions.com/form/paragonokc.com/restaurantquote" aria-label="Restaurant">Restaurant</a></li><li><a target="_self" href="https://secureformsolutions.com/form/paragonokc.com/truck" aria-label="Truck & Trucking">Truck & Trucking</a></li><li><a target="_self" href="https://secureformsolutions.com/form/paragonokc.com/workcomp" aria-label="Workers Compensation">Workers Compensation</a></li><li><a target="_self" href="https://secureformsolutions.com/form/paragonokc.com/hotel" aria-label="Hotel / Motel">Hotel / Motel</a></li><li><a target="_self" href="https://secureformsolutions.com/form/paragonokc.com/quickauto" aria-label="Auto Insurance Quick Form">Auto Insurance Quick Form</a></li><li><a target="_self" href="https://secureformsolutions.com/form/paragonokc.com/quickhome" aria-label="Home Insurance Quick Form">Home Insurance Quick Form</a></li></ul></li><li><a href="https://paragonokc.com/partners" target="_self" aria-label="Partners">Partners</a></li><li class="dropdown drop-cols-2"><a target="_self" href="https://paragonokc.com/customer-support" class="dropdown-toggle disabled" data-toggle="dropdown" role="button" aria-label="Support">Support <span class="caret"></span></a><ul class="dropdown-menu"><li><a target="_self" href="https://paragonokc.com/customer-support/payments-and-claims" aria-label="Payments & Claims">Payments & Claims</a></li><li><a target="_self" href="https://secureformsolutions.com/form/paragonokc.com/add_driver" aria-label="Add Driver Request Form">Add Driver Request Form</a></li><li><a target="_self" href="https://secureformsolutions.com/form/paragonokc.com/addvehicle" aria-label="Add a Vehicle Form">Add a Vehicle Form</a></li><li><a target="_self" href="https://secureformsolutions.com/form/paragonokc.com/autoid" aria-label="Auto ID Card Request">Auto ID Card Request</a></li><li><a target="_self" href="https://secureformsolutions.com/form/paragonokc.com/certrequest" aria-label="Certificate of Insurance">Certificate of Insurance</a></li><li><a target="_self" href="https://secureformsolutions.com/form/paragonokc.com/address" aria-label="Change of Address Form">Change of Address Form</a></li><li><a target="_self" href="https://secureformsolutions.com/form/paragonokc.com/commrenewal" aria-label="Commercial Renewal Review">Commercial Renewal Review</a></li><li><a target="_self" href="https://secureformsolutions.com/form/paragonokc.com/plrenewal" aria-label="Personal Renewal Review">Personal Renewal Review</a></li><li><a target="_self" href="https://secureformsolutions.com/form/paragonokc.com/policychange" aria-label="Policy Change Request">Policy Change Request</a></li><li><a target="_self" href="https://secureformsolutions.com/form/paragonokc.com/feedback" aria-label="Questions & Comments">Questions & Comments</a></li><li><a target="_self" href="https://secureformsolutions.com/form/paragonokc.com/remove_driver" aria-label="Remove Driver Form">Remove Driver Form</a></li><li><a target="_self" href="https://secureformsolutions.com/form/paragonokc.com/removevehicle" aria-label="Remove Vehicle Form">Remove Vehicle Form</a></li><li><a target="_self" href="https://secureformsolutions.com/form/paragonokc.com/survey" aria-label="Survey">Survey</a></li></ul></li><li class="dropdown drop-cols-1 hidden-sm"><a target="_self" href="https://paragonokc.com/customer-resources" class="dropdown-toggle disabled" data-toggle="dropdown" role="button" aria-label="Resources">Resources <span class="caret"></span></a><ul class="dropdown-menu"><li><a target="_self" href="https://paragonokc.com/customer-resources/insurance-companies" aria-label="Our Companies">Our Companies</a></li><li><a target="_self" href="https://secureformsolutions.com/form/paragonokc.com/client-center" aria-label="Client Center">Client Center</a></li><li><a target="_self" href="https://paragonokc.com/customer-resources/links" aria-label="Helpful Links">Helpful Links</a></li><li><a target="_self" href="https://paragonokc.com/customer-resources/privacy" aria-label="Privacy Policy Statement">Privacy Policy Statement</a></li><li><a target="_self" href="https://paragonokc.com/customer-resources/sitemap" aria-label="Site Map">Site Map</a></li><li><a target="_self" href="https://secureformsolutions.com/form/paragonokc.com/refer" aria-label="Refer a Friend">Refer a Friend</a></li><li><a target="_self" href="https://paragonokc.com/customer-resources/glossary" aria-label="Common Insurance Terms">Common Insurance Terms</a></li></ul></li><li><a href="https://paragonokc.com/blog" target="_self" aria-label="Blog">Blog</a></li><li class="dropdown drop-cols-1"><a target="_self" href="https://paragonokc.com/contact" class="dropdown-toggle disabled" data-toggle="dropdown" role="button" aria-label="Contact">Contact <span class="caret"></span></a><ul class="dropdown-menu"><li><a target="_self" href="https://paragonokc.com/contact/" aria-label="Piedmont Office">Piedmont Office</a></li><li><a target="_self" href="https://paragonokc.com/contact/557" aria-label="Shawnee Office">Shawnee Office</a></li></ul></li></ul></div></div></div></div></div></div></header></div><div class="sticky-social-container hidden-xs"><ul class="sticky-social"><li><a href="https://www.facebook.com/ParagonInsuranceOKC/" class="clearfix" aria-label="Visit Facebook (opens in a new tab)" target="_blank"><img src="https://alicorsolutions.com/cdn/social/material/facebook.png" alt="" aria-hidden="true"> <span class="social-title">Facebook</span></a></li><li><a href="https://twitter.com/paragonokc" class="clearfix" aria-label="Visit Twitter (opens in a new tab)" target="_blank"><img src="https://alicorsolutions.com/cdn/social/material/twitter.png" alt="" aria-hidden="true"> <span class="social-title">Twitter</span></a></li><li><a href="https://www.linkedin.com/company/paragonokc/" class="clearfix" aria-label="Visit LinkedIn (opens in a new tab)" target="_blank"><img src="https://alicorsolutions.com/cdn/social/material/linkedin.png" alt="" aria-hidden="true"> <span class="social-title">LinkedIn</span></a></li><li><a href="https://www.yelp.com/biz/paragon-insurance-piedmont" class="clearfix" aria-label="Visit Yelp (opens in a new tab)" target="_blank"><img src="https://alicorsolutions.com/cdn/social/material/yelp.png" alt="" aria-hidden="true"> <span class="social-title">Yelp</span></a></li><li><a href="https://https://www.instagram.com/paragonokc/" class="clearfix" aria-label="Visit Instagram (opens in a new tab)" target="_blank"><img src="https://alicorsolutions.com/cdn/social/material/instagram.png" alt="" aria-hidden="true"> <span class="social-title">Instagram</span></a></li><li><a href="https://paragonokc.com/blog" class="clearfix" aria-label="Visit Blog (opens in a new tab)"><img src="https://alicorsolutions.com/cdn/social/material/blog.png" alt="" aria-hidden="true"> <span class="social-title">Blog</span></a></li></ul></div><div class="content-wrapper"><div class="container"><div class="row"><div class="col-md-12 hidden-xs"><ul class="breadcrumb"><li><a href="./"><img alt="Home Page" src="https://alicorsolutions.com/cdn/icon/64/000000/home.png"></a> <span class="divider"></span></li><li class="active">Secure Form</li></ul></div></div><div class="row"><main class="col-xs-12"> <div class="page-footer"><div id="sfs"><div> <div id="title_div"> <h1>Secure Remove Vehicle Request Form</h1> </div> <script src="https://www.google.com/recaptcha/api.js" async defer></script> <script> function submitFinish(token) { var input = $("<input>") .attr("type", "hidden") .attr("name", "finish") .val("Finish"); $('#supform').append(input).submit(); } </script> <div id="basics_div"> <form id="supform" name="form1" action="https://secureformsolutions.com/form.php?ref=paragonokc.com&form=removevehicle" method="post" onsubmit="return checkVals()"> <input type="hidden" name="form_name" value="removevehicle" /> <input type="hidden" name="form_section" value="support" /> <input type="hidden" name="form_id" value="25" /> <input type="hidden" name="form_domain" value="paragonokc.com" /> <div class="smurf-container"><div class="smurf"><input type="text" name="smurf" value="" /></div></div> <fieldset class="sfs-fieldset"> <div class="sfs-input-group clearfix"> <div class="sfs-input-title"><div id="names"> <table border="0" cellspacing="0" cellpadding="0"> <tr> <td> </td> </tr> <tr> <td>Your Name:</td> </tr> </table> </div> </div> <div class="sfs-input-wrapper"> <table border="0" cellspacing="0" cellpadding="0"> <tr> <td class="fine_print" style="padding-left:5px">First</td> <td class="fine_print" style="padding-left:5px">Last</td> </tr> <tr> <td><input type="text" name="fname" id="fname" style="width: 80px" /></td> <td><input type="text" name="lname" id="lname" style="width: 116px" /></td> </tr> </table> </div> </div> <div class="sfs-input-group clearfix"> <div class="sfs-input-title"><label>Email Address:</label></div> <div class="sfs-input-wrapper"><input type="text" name="email" id="email" size="30" /></div> </div> <div class="sfs-input-group clearfix"> <div class="sfs-input-title"><label>Phone Number:</label></div> <div class="sfs-input-wrapper"><input type="text" name="phone" id="phone" size="30" /></div> </div> <div class="sfs-input-group clearfix"> <div class="sfs-input-title"><label>5 Digit Zip:</label></div> <div class="sfs-input-wrapper"><input type="text" name="zip" id="zip" size="30" /></div> </div> </fieldset> <div style="padding:10px 0"><fieldset class="sfs-fieldset"> <div class="sfs-input-group clearfix"> <div class="sfs-input-title"> Policy Number: </div> <div class="sfs-input-wrapper"> <input type="text" name="form_data[policy_info][policy_number]" /> </div> </div> <div class="sfs-input-group clearfix"> <div class="sfs-input-title"><label>Effective Date:</label></div> <div class="sfs-input-wrapper"> <select name="form_data[policy_info][_date_effective_date][month]"> <option value="00">Month</option> <option value="01">January</option> <option value="02">February</option> <option value="03">March</option> <option value="04">April</option> <option value="05">May</option> <option value="06">June</option> <option value="07">July</option> <option value="08">August</option> <option value="09">September</option> <option value="10">October</option> <option value="11" selected="selected">November</option> <option value="12">December</option> </select> <select name="form_data[policy_info][_date_effective_date][day]"> <option value="00">Day</option> <option value="01">01</option> <option value="02">02</option> <option value="03">03</option> <option value="04">04</option> <option value="05">05</option> <option value="06">06</option> <option value="07">07</option> <option value="08">08</option> <option value="09">09</option> <option value="10">10</option> <option value="11">11</option> <option value="12">12</option> <option value="13">13</option> <option value="14">14</option> <option value="15">15</option> <option value="16">16</option> <option value="17">17</option> <option value="18">18</option> <option value="19">19</option> <option value="20">20</option> <option value="21">21</option> <option value="22">22</option> <option value="23">23</option> <option value="24">24</option> <option value="25">25</option> <option value="26">26</option> <option value="27">27</option> <option value="28">28</option> <option value="29">29</option> <option value="30" selected="selected">30</option> <option value="31">31</option> </select> <select name="form_data[policy_info][_date_effective_date][year]"> <option value="0000">Year</option> <option value="2024" selected="selected">2024</option> <option value="2025">2025</option> <option value="2026">2026</option> <option value="2027">2027</option> </select> </div> </div> </fieldset> <h3>Vehicle Information</h3> <fieldset class="sfs-fieldset"> <div class="sfs-input-group clearfix"> <div class="sfs-input-title"><label>Number of Vehicles to Remove:</label></div> <div class="sfs-input-wrapper"> <select name="form_data[remove_vehicle][_set_number_to_remove]" id="Number_to_Remove" onchange="javscript: ShowMenu(document.getElementById('Number_to_Remove').value,'divNumber_to_Remove', 5);"> <option value="1">1</option> <option value="2">2</option> <option value="3">3</option> <option value="4">4</option> <option value="5">5</option> </select> </div> </div> </fieldset> <div id="divNumber_to_Remove1""> <fieldset class="sfs-fieldset"> <caption align="top"> <h4>Vehicle 1</h4> </caption> <div class="sfs-input-group clearfix"> <div class="sfs-input-title"> Vehicle 1 Year: </div> <div class="sfs-input-wrapper"> <input type="text" name="form_data[remove_vehicle][year_1]" /> </div> </div> <div class="sfs-input-group clearfix"> <div class="sfs-input-title"> Vehicle 1 Make: </div> <div class="sfs-input-wrapper"> <input type="text" name="form_data[remove_vehicle][make_1]" /> </div> </div> <div class="sfs-input-group clearfix"> <div class="sfs-input-title"> Vehicle 1 Model: </div> <div class="sfs-input-wrapper"> <input type="text" name="form_data[remove_vehicle][model_1]" /> </div> </div> <div class="sfs-input-group clearfix"> <div class="sfs-input-title"> Vehicle 1 VIN: </div> <div class="sfs-input-wrapper"> <input type="text" name="form_data[remove_vehicle][VIN_1]" /> </div> </div> </fieldset> </div> <div id="divNumber_to_Remove2" style="display:none"> <fieldset class="sfs-fieldset"> <caption align="top"> <h4>Vehicle 2</h4> </caption> <div class="sfs-input-group clearfix"> <div class="sfs-input-title"> Vehicle 2 Year: </div> <div class="sfs-input-wrapper"> <input type="text" name="form_data[remove_vehicle][year_2]" /> </div> </div> <div class="sfs-input-group clearfix"> <div class="sfs-input-title"> Vehicle 2 Make: </div> <div class="sfs-input-wrapper"> <input type="text" name="form_data[remove_vehicle][make_2]" /> </div> </div> <div class="sfs-input-group clearfix"> <div class="sfs-input-title"> Vehicle 2 Model: </div> <div class="sfs-input-wrapper"> <input type="text" name="form_data[remove_vehicle][model_2]" /> </div> </div> <div class="sfs-input-group clearfix"> <div class="sfs-input-title"> Vehicle 2 VIN: </div> <div class="sfs-input-wrapper"> <input type="text" name="form_data[remove_vehicle][VIN_2]" /> </div> </div> </fieldset> </div> <div id="divNumber_to_Remove3" style="display:none"> <fieldset class="sfs-fieldset"> <caption align="top"> <h4>Vehicle 3</h4> </caption> <div class="sfs-input-group clearfix"> <div class="sfs-input-title"> Vehicle 3 Year: </div> <div class="sfs-input-wrapper"> <input type="text" name="form_data[remove_vehicle][year_3]" /> </div> </div> <div class="sfs-input-group clearfix"> <div class="sfs-input-title"> Vehicle 3 Make: </div> <div class="sfs-input-wrapper"> <input type="text" name="form_data[remove_vehicle][make_3]" /> </div> </div> <div class="sfs-input-group clearfix"> <div class="sfs-input-title"> Vehicle 3 Model: </div> <div class="sfs-input-wrapper"> <input type="text" name="form_data[remove_vehicle][model_3]" /> </div> </div> <div class="sfs-input-group clearfix"> <div class="sfs-input-title"> Vehicle 3 VIN: </div> <div class="sfs-input-wrapper"> <input type="text" name="form_data[remove_vehicle][VIN_3]" /> </div> </div> </fieldset> </div> <div id="divNumber_to_Remove4" style="display:none"> <fieldset class="sfs-fieldset"> <caption align="top"> <h4>Vehicle 4</h4> </caption> <div class="sfs-input-group clearfix"> <div class="sfs-input-title"> Vehicle 4 Year: </div> <div class="sfs-input-wrapper"> <input type="text" name="form_data[remove_vehicle][year_4]" /> </div> </div> <div class="sfs-input-group clearfix"> <div class="sfs-input-title"> Vehicle 4 Make: </div> <div class="sfs-input-wrapper"> <input type="text" name="form_data[remove_vehicle][make_4]" /> </div> </div> <div class="sfs-input-group clearfix"> <div class="sfs-input-title"> Vehicle 4 Model: </div> <div class="sfs-input-wrapper"> <input type="text" name="form_data[remove_vehicle][model_4]" /> </div> </div> <div class="sfs-input-group clearfix"> <div class="sfs-input-title"> Vehicle 4 VIN: </div> <div class="sfs-input-wrapper"> <input type="text" name="form_data[remove_vehicle][VIN_4]" /> </div> </div> </fieldset> </div> <div id="divNumber_to_Remove5" style="display:none"> <fieldset class="sfs-fieldset"> <caption align="top"> <h4>Vehicle 5</h4> </caption> <div class="sfs-input-group clearfix"> <div class="sfs-input-title"> Vehicle 5 Year: </div> <div class="sfs-input-wrapper"> <input type="text" name="form_data[remove_vehicle][year_5]" /> </div> </div> <div class="sfs-input-group clearfix"> <div class="sfs-input-title"> Vehicle 5 Make: </div> <div class="sfs-input-wrapper"> <input type="text" name="form_data[remove_vehicle][make_5]" /> </div> </div> <div class="sfs-input-group clearfix"> <div class="sfs-input-title"> Vehicle 5 Model: </div> <div class="sfs-input-wrapper"> <input type="text" name="form_data[remove_vehicle][model_5]" /> </div> </div> <div class="sfs-input-group clearfix"> <div class="sfs-input-title"> Vehicle 5 VIN: </div> <div class="sfs-input-wrapper"> <input type="text" name="form_data[remove_vehicle][VIN_5]" /> </div> </div> </fieldset> </div> <h3>Add Vehicle Option</h3> <fieldset class="sfs-fieldset"> <div class="sfs-input-group clearfix"> <div class="sfs-input-title"><label>Number of Vehicles to Add:</label></div> <div class="sfs-input-wrapper"> <select name="form_data[vehicle_info][_set_number_of_vehicles]" id="Number_of_Vehicles" onchange="javscript: ShowMenu(document.getElementById('Number_of_Vehicles').value,'divNumber_of_Vehicles', 5);"> <option value="0">0</option> <option value="1">1</option> <option value="2">2</option> <option value="3">3</option> <option value="4">4</option> <option value="5">5</option> </select> </div> </div> </fieldset> <div id="divNumber_of_Vehicles1" style="display:none"> <fieldset class="sfs-fieldset"> <caption align="top"> <h4>Vehicle 1</h4> </caption> <div class="sfs-input-group clearfix"> <div class="sfs-input-title"> Vehicle 1 Year: </div> <div class="sfs-input-wrapper"> <input type="text" name="form_data[vehicle_info][year_1]" /> </div> </div> <div class="sfs-input-group clearfix"> <div class="sfs-input-title"> Vehicle 1 Make: </div> <div class="sfs-input-wrapper"> <input type="text" name="form_data[vehicle_info][make_1]" /> </div> </div> <div class="sfs-input-group clearfix"> <div class="sfs-input-title"> Vehicle 1 Model: </div> <div class="sfs-input-wrapper"> <input type="text" name="form_data[vehicle_info][model_1]" /> </div> </div> <div class="sfs-input-group clearfix"> <div class="sfs-input-title"> Vehicle 1 VIN: </div> <div class="sfs-input-wrapper"> <input type="text" name="form_data[vehicle_info][VIN_1]" /> </div> </div> <div class="sfs-input-group clearfix"> <div class="sfs-input-title"> Primary Driver: </div> <div class="sfs-input-wrapper"> <input type="text" name="form_data[vehicle_info][primary_driver_1]" value=" " /> </div> </div> <div class="sfs-input-group clearfix"> <div class="sfs-input-title"> Current Odometer: </div> <div class="sfs-input-wrapper"> <input type="text" name="form_data[vehicle_info][current_odometer_1]" /> </div> </div> <div class="sfs-input-group clearfix"> <div class="sfs-input-title"> Estimated Yearly Mileage: </div> <div class="sfs-input-wrapper"> <input type="text" name="form_data[vehicle_info][yearly_mileage_1]" /> </div> </div> <div class="sfs-input-group clearfix"> <div class="sfs-input-title"> Ownership: </div> <div class="sfs-input-wrapper"> <select name="form_data[vehicle_info][ownership_1]"> <option value="Not Selected">Select...</option> <option value="Owned">Owned</option> <option value="Leased">Leased</option> <option value="Financed">Financed</option> <option value="Lien">Lien</option> <option value="Loan">Loan</option> <option value="Other">Other</option> </select> </div> </div> <div class="sfs-input-group clearfix"> <div class="sfs-input-title"> Primary Use: </div> <div class="sfs-input-wrapper"> <select name="form_data[vehicle_info][use_1]"> <option value="Not Selected">Select...</option> <option value="Business">Business</option> <option value="Farming">Farming</option> <option value="Pleasure">Pleasure</option> <option value="To/From Work">To/From Work</option> <option value="To/From School">To/From School</option> </select> </div> </div> <div class="sfs-input-group clearfix"> <div class="sfs-input-title"> Anti Theft Features: </div> <div class="sfs-input-wrapper"> <select size="5" multiple="multiple" name="form_data[vehicle_info][anti_theft_features_1][]"> <option value="Not Selected">Select...</option> <option value="None">None</option> <option value="Alarm ">Alarm </option> <option value="Vehicle Recovery System">Vehicle Recovery System</option> <option value="VIN Etching">VIN Etching</option> <option value="Other">Other</option> </select> </div> </div> <div class="sfs-input-group clearfix"> <div class="sfs-input-title"> Passive Restraints: </div> <div class="sfs-input-wrapper"> <select size="5" multiple="multiple" name="form_data[vehicle_info][passive_restraints_1][]"> <option value="Not Selected">Select...</option> <option value="None">None</option> <option value="Automatic Seatbelts ">Automatic Seatbelts </option> <option value="Driver Side Airbag">Driver Side Airbag</option> <option value="Passenger Airbag">Passenger Airbag</option> <option value="Side Curtain Airbag">Side Curtain Airbag</option> <option value="Other">Other</option> </select> </div> </div> <div class="sfs-input-group clearfix"> <div class="sfs-input-title"> Anti-Lock Brakes: </div> <div class="sfs-input-wrapper"> <select name="form_data[vehicle_info][Anti-Lock_brakes_1]"> <option value="Not Selected">Select...</option> <option value="Yes">Yes</option> <option value="No">No</option> </select> </div> </div> <div class="sfs-input-group clearfix"> <div class="sfs-input-title"> Daytime Running Lights: </div> <div class="sfs-input-wrapper"> <select name="form_data[vehicle_info][daytime_running_lights_1]"> <option value="Not Selected">Select...</option> <option value="Yes">Yes</option> <option value="No">No</option> </select> </div> </div> <div class="sfs-input-group clearfix"> <div class="sfs-input-title"> Any Prior Damage to Vehicle? </div> <div class="sfs-input-wrapper"> <select name="form_data[vehicle_info][prior_damage_1]"> <option value="Not Selected">Select...</option> <option value="No">No</option> <option value="Yes">Yes</option> </select> </div> </div> <div class="sfs-input-group clearfix"> <div class="sfs-input-title"> Vehicle Ever Used for Deliveries? </div> <div class="sfs-input-wrapper"> <select name="form_data[vehicle_info][used_for_delivery_1]"> <option value="Not Selected">Select...</option> <option value="No">No</option> <option value="Yes">Yes</option> </select> </div> </div> <div class="sfs-input-group clearfix"> <div class="sfs-input-title"> Comprehensive Deductible: </div> <div class="sfs-input-wrapper"> <select name="form_data[vehicle_info][comprehensive_deductible_1]"> <option value="Not Selected">Select...</option> <option value="No Coverage">No Coverage</option> <option value="0">0</option> <option value="50">50</option> <option value="100">100</option> <option value="200">200</option> <option value="250">250</option> <option value="500">500</option> <option value="1000">1000</option> </select> </div> </div> <div class="sfs-input-group clearfix"> <div class="sfs-input-title"> Collision Deductible: </div> <div class="sfs-input-wrapper"> <select name="form_data[vehicle_info][collision_deductible_1]"> <option value="Not Selected">Select...</option> <option value="No Coverage">No Coverage</option> <option value="0">0</option> <option value="50">50</option> <option value="100">100</option> <option value="200">200</option> <option value="250">250</option> <option value="500">500</option> <option value="1000">1000</option> </select> </div> </div> <div class="sfs-input-group clearfix"> <div class="sfs-input-title"> Full Glass Coverage? </div> <div class="sfs-input-wrapper"> <select name="form_data[vehicle_info][collision_deductible_1]"> <option value="Not Selected">Select...</option> <option value="No">No</option> <option value="Yes">Yes</option> </select> </div> </div> <div class="sfs-input-group clearfix"> <div class="sfs-input-title"><label>Addition Effective Date:</label></div> <div class="sfs-input-wrapper"> <select name="form_data[vehicle_info][_date_add_effective_date_1][month]"> <option value="00">Month</option> <option value="01">January</option> <option value="02">February</option> <option value="03">March</option> <option value="04">April</option> <option value="05">May</option> <option value="06">June</option> <option value="07">July</option> <option value="08">August</option> <option value="09">September</option> <option value="10">October</option> <option value="11" selected="selected">November</option> <option value="12">December</option> </select> <select name="form_data[vehicle_info][_date_add_effective_date_1][day]"> <option value="00">Day</option> <option value="01">01</option> <option value="02">02</option> <option value="03">03</option> <option value="04">04</option> <option value="05">05</option> <option value="06">06</option> <option value="07">07</option> <option value="08">08</option> <option value="09">09</option> <option value="10">10</option> <option value="11">11</option> <option value="12">12</option> <option value="13">13</option> <option value="14">14</option> <option value="15">15</option> <option value="16">16</option> <option value="17">17</option> <option value="18">18</option> <option value="19">19</option> <option value="20">20</option> <option value="21">21</option> <option value="22">22</option> <option value="23">23</option> <option value="24">24</option> <option value="25">25</option> <option value="26">26</option> <option value="27">27</option> <option value="28">28</option> <option value="29">29</option> <option value="30" selected="selected">30</option> <option value="31">31</option> </select> <select name="form_data[vehicle_info][_date_add_effective_date_1][year]"> <option value="0000">Year</option> <option value="2024" selected="selected">2024</option> <option value="2025">2025</option> <option value="2026">2026</option> <option value="2027">2027</option> </select> </div> </div> </fieldset> </div> <div id="divNumber_of_Vehicles2" style="display:none"> <fieldset class="sfs-fieldset"> <caption align="top"> <h4>Vehicle 2</h4> </caption> <div class="sfs-input-group clearfix"> <div class="sfs-input-title"> Vehicle 2 Year: </div> <div class="sfs-input-wrapper"> <input type="text" name="form_data[vehicle_info][year_2]" /> </div> </div> <div class="sfs-input-group clearfix"> <div class="sfs-input-title"> Vehicle 2 Make: </div> <div class="sfs-input-wrapper"> <input type="text" name="form_data[vehicle_info][make_2]" /> </div> </div> <div class="sfs-input-group clearfix"> <div class="sfs-input-title"> Vehicle 2 Model: </div> <div class="sfs-input-wrapper"> <input type="text" name="form_data[vehicle_info][model_2]" /> </div> </div> <div class="sfs-input-group clearfix"> <div class="sfs-input-title"> Vehicle 2 VIN: </div> <div class="sfs-input-wrapper"> <input type="text" name="form_data[vehicle_info][VIN_2]" /> </div> </div> <div class="sfs-input-group clearfix"> <div class="sfs-input-title"> Primary Driver: </div> <div class="sfs-input-wrapper"> <input type="text" name="form_data[vehicle_info][primary_driver_2]" /> </div> </div> <div class="sfs-input-group clearfix"> <div class="sfs-input-title"> Current Odometer: </div> <div class="sfs-input-wrapper"> <input type="text" name="form_data[vehicle_info][current_odometer_2]" /> </div> </div> <div class="sfs-input-group clearfix"> <div class="sfs-input-title"> Estimated Yearly Mileage: </div> <div class="sfs-input-wrapper"> <input type="text" name="form_data[vehicle_info][yearly_mileage_2]" /> </div> </div> <div class="sfs-input-group clearfix"> <div class="sfs-input-title"> Ownership: </div> <div class="sfs-input-wrapper"> <select name="form_data[vehicle_info][ownership_2]"> <option value="Not Selected">Select...</option> <option value="Owned">Owned</option> <option value="Leased">Leased</option> <option value="Financed">Financed</option> <option value="Lien">Lien</option> <option value="Loan">Loan</option> <option value="Other">Other</option> </select> </div> </div> <div class="sfs-input-group clearfix"> <div class="sfs-input-title"> Primary Use: </div> <div class="sfs-input-wrapper"> <select name="form_data[vehicle_info][use_2]"> <option value="Not Selected">Select...</option> <option value="Business">Business</option> <option value="Farming">Farming</option> <option value="Pleasure">Pleasure</option> <option value="To/From Work">To/From Work</option> <option value="To/From School">To/From School</option> </select> </div> </div> <div class="sfs-input-group clearfix"> <div class="sfs-input-title"> Anti Theft Features: </div> <div class="sfs-input-wrapper"> <select size="5" multiple="multiple" name="form_data[vehicle_info][anti_theft_features_2][]"> <option value="Not Selected">Select...</option> <option value="None">None</option> <option value="Alarm ">Alarm </option> <option value="Vehicle Recovery System">Vehicle Recovery System</option> <option value="VIN Etching">VIN Etching</option> <option value="Other">Other</option> </select> </div> </div> <div class="sfs-input-group clearfix"> <div class="sfs-input-title"> Passive Restraints: </div> <div class="sfs-input-wrapper"> <select size="5" multiple="multiple" name="form_data[vehicle_info][passive_restraints_2][]"> <option value="Not Selected">Select...</option> <option value="None">None</option> <option value="Automatic Seatbelts ">Automatic Seatbelts </option> <option value="Driver Side Airbag">Driver Side Airbag</option> <option value="Passenger Airbag">Passenger Airbag</option> <option value="Side Curtain Airbag">Side Curtain Airbag</option> <option value="Other">Other</option> </select> </div> </div> <div class="sfs-input-group clearfix"> <div class="sfs-input-title"> Anti-Lock Brakes: </div> <div class="sfs-input-wrapper"> <select name="form_data[vehicle_info][Anti-Lock_brakes_2]"> <option value="Not Selected">Select...</option> <option value="Yes">Yes</option> <option value="No">No</option> </select> </div> </div> <div class="sfs-input-group clearfix"> <div class="sfs-input-title"> Daytime Running Lights: </div> <div class="sfs-input-wrapper"> <select name="form_data[vehicle_info][daytime_running_lights_2]"> <option value="Not Selected">Select...</option> <option value="Yes">Yes</option> <option value="No">No</option> </select> </div> </div> <div class="sfs-input-group clearfix"> <div class="sfs-input-title"> Any Prior Damage to Vehicle? </div> <div class="sfs-input-wrapper"> <select name="form_data[vehicle_info][prior_damage_2]"> <option value="Not Selected">Select...</option> <option value="No">No</option> <option value="Yes">Yes</option> </select> </div> </div> <div class="sfs-input-group clearfix"> <div class="sfs-input-title"> Vehicle Ever Used for Deliveries? </div> <div class="sfs-input-wrapper"> <select name="form_data[vehicle_info][used_for_delivery_2]"> <option value="Not Selected">Select...</option> <option value="No">No</option> <option value="Yes">Yes</option> </select> </div> </div> <div class="sfs-input-group clearfix"> <div class="sfs-input-title"> Comprehensive Deductible: </div> <div class="sfs-input-wrapper"> <select name="form_data[vehicle_info][comprehensive_deductible_2]"> <option value="Not Selected">Select...</option> <option value="No Coverage">No Coverage</option> <option value="0">0</option> <option value="50">50</option> <option value="100">100</option> <option value="200">200</option> <option value="250">250</option> <option value="500">500</option> <option value="1000">1000</option> </select> </div> </div> <div class="sfs-input-group clearfix"> <div class="sfs-input-title"> Collision Deductible: </div> <div class="sfs-input-wrapper"> <select name="form_data[vehicle_info][collision_deductible_2]"> <option value="Not Selected">Select...</option> <option value="No Coverage">No Coverage</option> <option value="0">0</option> <option value="50">50</option> <option value="100">100</option> <option value="200">200</option> <option value="250">250</option> <option value="500">500</option> <option value="1000">1000</option> </select> </div> </div> <div class="sfs-input-group clearfix"> <div class="sfs-input-title"> Full Glass Coverage? </div> <div class="sfs-input-wrapper"> <select name="form_data[vehicle_info][collision_deductible_2]"> <option value="Not Selected">Select...</option> <option value="No">No</option> <option value="Yes">Yes</option> </select> </div> </div> <div class="sfs-input-group clearfix"> <div class="sfs-input-title"><label>Addition Effective Date:</label></div> <div class="sfs-input-wrapper"> <select name="form_data[vehicle_info][_date_add_effective_date_2][month]"> <option value="00">Month</option> <option value="01">January</option> <option value="02">February</option> <option value="03">March</option> <option value="04">April</option> <option value="05">May</option> <option value="06">June</option> <option value="07">July</option> <option value="08">August</option> <option value="09">September</option> <option value="10">October</option> <option value="11" selected="selected">November</option> <option value="12">December</option> </select> <select name="form_data[vehicle_info][_date_add_effective_date_2][day]"> <option value="00">Day</option> <option value="01">01</option> <option value="02">02</option> <option value="03">03</option> <option value="04">04</option> <option value="05">05</option> <option value="06">06</option> <option value="07">07</option> <option value="08">08</option> <option value="09">09</option> <option value="10">10</option> <option value="11">11</option> <option value="12">12</option> <option value="13">13</option> <option value="14">14</option> <option value="15">15</option> <option value="16">16</option> <option value="17">17</option> <option value="18">18</option> <option value="19">19</option> <option value="20">20</option> <option value="21">21</option> <option value="22">22</option> <option value="23">23</option> <option value="24">24</option> <option value="25">25</option> <option value="26">26</option> <option value="27">27</option> <option value="28">28</option> <option value="29">29</option> <option value="30" selected="selected">30</option> <option value="31">31</option> </select> <select name="form_data[vehicle_info][_date_add_effective_date_2][year]"> <option value="0000">Year</option> <option value="2024" selected="selected">2024</option> <option value="2025">2025</option> <option value="2026">2026</option> <option value="2027">2027</option> </select> </div> </div> </fieldset> </div> <div id="divNumber_of_Vehicles3" style="display:none"> <fieldset class="sfs-fieldset"> <caption align="top"> <h4>Vehicle 3</h4> </caption> <div class="sfs-input-group clearfix"> <div class="sfs-input-title"> Vehicle 3 Year: </div> <div class="sfs-input-wrapper"> <input type="text" name="form_data[vehicle_info][year_3]" /> </div> </div> <div class="sfs-input-group clearfix"> <div class="sfs-input-title"> Vehicle 3 Make: </div> <div class="sfs-input-wrapper"> <input type="text" name="form_data[vehicle_info][make_3]" /> </div> </div> <div class="sfs-input-group clearfix"> <div class="sfs-input-title"> Vehicle 3 Model: </div> <div class="sfs-input-wrapper"> <input type="text" name="form_data[vehicle_info][model_3]" /> </div> </div> <div class="sfs-input-group clearfix"> <div class="sfs-input-title"> Vehicle 3 VIN: </div> <div class="sfs-input-wrapper"> <input type="text" name="form_data[vehicle_info][VIN_3]" /> </div> </div> <div class="sfs-input-group clearfix"> <div class="sfs-input-title"> Primary Driver: </div> <div class="sfs-input-wrapper"> <input type="text" name="form_data[vehicle_info][primary_driver_3]" /> </div> </div> <div class="sfs-input-group clearfix"> <div class="sfs-input-title"> Current Odometer: </div> <div class="sfs-input-wrapper"> <input type="text" name="form_data[vehicle_info][current_odometer_3]" /> </div> </div> <div class="sfs-input-group clearfix"> <div class="sfs-input-title"> Estimated Yearly Mileage: </div> <div class="sfs-input-wrapper"> <input type="text" name="form_data[vehicle_info][yearly_mileage_3]" /> </div> </div> <div class="sfs-input-group clearfix"> <div class="sfs-input-title"> Ownership: </div> <div class="sfs-input-wrapper"> <select name="form_data[vehicle_info][ownership_3]"> <option value="Not Selected">Select...</option> <option value="Owned">Owned</option> <option value="Leased">Leased</option> <option value="Financed">Financed</option> <option value="Lien">Lien</option> <option value="Loan">Loan</option> <option value="Other">Other</option> </select> </div> </div> <div class="sfs-input-group clearfix"> <div class="sfs-input-title"> Primary Use: </div> <div class="sfs-input-wrapper"> <select name="form_data[vehicle_info][use_3]"> <option value="Not Selected">Select...</option> <option value="Business">Business</option> <option value="Farming">Farming</option> <option value="Pleasure">Pleasure</option> <option value="To/From Work">To/From Work</option> <option value="To/From School">To/From School</option> </select> </div> </div> <div class="sfs-input-group clearfix"> <div class="sfs-input-title"> Anti Theft Features: </div> <div class="sfs-input-wrapper"> <select size="5" multiple="multiple" name="form_data[vehicle_info][anti_theft_features_3][]"> <option value="Not Selected">Select...</option> <option value="None">None</option> <option value="Alarm ">Alarm </option> <option value="Vehicle Recovery System">Vehicle Recovery System</option> <option value="VIN Etching">VIN Etching</option> <option value="Other">Other</option> </select> </div> </div> <div class="sfs-input-group clearfix"> <div class="sfs-input-title"> Passive Restraints: </div> <div class="sfs-input-wrapper"> <select size="5" multiple="multiple" name="form_data[vehicle_info][passive_restraints_3][]"> <option value="Not Selected">Select...</option> <option value="None">None</option> <option value="Automatic Seatbelts ">Automatic Seatbelts </option> <option value="Driver Side Airbag">Driver Side Airbag</option> <option value="Passenger Airbag">Passenger Airbag</option> <option value="Side Curtain Airbag">Side Curtain Airbag</option> <option value="Other">Other</option> </select> </div> </div> <div class="sfs-input-group clearfix"> <div class="sfs-input-title"> Anti-Lock Brakes: </div> <div class="sfs-input-wrapper"> <select name="form_data[vehicle_info][Anti-Lock_brakes_3]"> <option value="Not Selected">Select...</option> <option value="Yes">Yes</option> <option value="No">No</option> </select> </div> </div> <div class="sfs-input-group clearfix"> <div class="sfs-input-title"> Daytime Running Lights: </div> <div class="sfs-input-wrapper"> <select name="form_data[vehicle_info][daytime_running_lights_3]"> <option value="Not Selected">Select...</option> <option value="Yes">Yes</option> <option value="No">No</option> </select> </div> </div> <div class="sfs-input-group clearfix"> <div class="sfs-input-title"> Any Prior Damage to Vehicle? </div> <div class="sfs-input-wrapper"> <select name="form_data[vehicle_info][prior_damage_3]"> <option value="Not Selected">Select...</option> <option value="No">No</option> <option value="Yes">Yes</option> </select> </div> </div> <div class="sfs-input-group clearfix"> <div class="sfs-input-title"> Vehicle Ever Used for Deliveries? </div> <div class="sfs-input-wrapper"> <select name="form_data[vehicle_info][used_for_delivery_3]"> <option value="Not Selected">Select...</option> <option value="No">No</option> <option value="Yes">Yes</option> </select> </div> </div> <div class="sfs-input-group clearfix"> <div class="sfs-input-title"> Comprehensive Deductible: </div> <div class="sfs-input-wrapper"> <select name="form_data[vehicle_info][comprehensive_deductible_3]"> <option value="Not Selected">Select...</option> <option value="No Coverage">No Coverage</option> <option value="0">0</option> <option value="50">50</option> <option value="100">100</option> <option value="200">200</option> <option value="250">250</option> <option value="500">500</option> <option value="1000">1000</option> </select> </div> </div> <div class="sfs-input-group clearfix"> <div class="sfs-input-title"> Collision Deductible: </div> <div class="sfs-input-wrapper"> <select name="form_data[vehicle_info][collision_deductible_3]"> <option value="Not Selected">Select...</option> <option value="No Coverage">No Coverage</option> <option value="0">0</option> <option value="50">50</option> <option value="100">100</option> <option value="200">200</option> <option value="250">250</option> <option value="500">500</option> <option value="1000">1000</option> </select> </div> </div> <div class="sfs-input-group clearfix"> <div class="sfs-input-title"> Full Glass Coverage? </div> <div class="sfs-input-wrapper"> <select name="form_data[vehicle_info][collision_deductible_3]"> <option value="Not Selected">Select...</option> <option value="No">No</option> <option value="Yes">Yes</option> </select> </div> </div> <div class="sfs-input-group clearfix"> <div class="sfs-input-title"><label>Addition Effective Date:</label></div> <div class="sfs-input-wrapper"> <select name="form_data[vehicle_info][_date_add_effective_date_3][month]"> <option value="00">Month</option> <option value="01">January</option> <option value="02">February</option> <option value="03">March</option> <option value="04">April</option> <option value="05">May</option> <option value="06">June</option> <option value="07">July</option> <option value="08">August</option> <option value="09">September</option> <option value="10">October</option> <option value="11" selected="selected">November</option> <option value="12">December</option> </select> <select name="form_data[vehicle_info][_date_add_effective_date_3][day]"> <option value="00">Day</option> <option value="01">01</option> <option value="02">02</option> <option value="03">03</option> <option value="04">04</option> <option value="05">05</option> <option value="06">06</option> <option value="07">07</option> <option value="08">08</option> <option value="09">09</option> <option value="10">10</option> <option value="11">11</option> <option value="12">12</option> <option value="13">13</option> <option value="14">14</option> <option value="15">15</option> <option value="16">16</option> <option value="17">17</option> <option value="18">18</option> <option value="19">19</option> <option value="20">20</option> <option value="21">21</option> <option value="22">22</option> <option value="23">23</option> <option value="24">24</option> <option value="25">25</option> <option value="26">26</option> <option value="27">27</option> <option value="28">28</option> <option value="29">29</option> <option value="30" selected="selected">30</option> <option value="31">31</option> </select> <select name="form_data[vehicle_info][_date_add_effective_date_3][year]"> <option value="0000">Year</option> <option value="2024" selected="selected">2024</option> <option value="2025">2025</option> <option value="2026">2026</option> <option value="2027">2027</option> </select> </div> </div> </fieldset> </div> <div id="divNumber_of_Vehicles4" style="display:none"> <fieldset class="sfs-fieldset"> <caption align="top"> <h4>Vehicle 4</h4> </caption> <div class="sfs-input-group clearfix"> <div class="sfs-input-title"> Vehicle 4 Year: </div> <div class="sfs-input-wrapper"> <input type="text" name="form_data[vehicle_info][year_4]" /> </div> </div> <div class="sfs-input-group clearfix"> <div class="sfs-input-title"> Vehicle 4 Make: </div> <div class="sfs-input-wrapper"> <input type="text" name="form_data[vehicle_info][make_4]" /> </div> </div> <div class="sfs-input-group clearfix"> <div class="sfs-input-title"> Vehicle 4 Model: </div> <div class="sfs-input-wrapper"> <input type="text" name="form_data[vehicle_info][model_4]" /> </div> </div> <div class="sfs-input-group clearfix"> <div class="sfs-input-title"> Vehicle 4 VIN: </div> <div class="sfs-input-wrapper"> <input type="text" name="form_data[vehicle_info][VIN_4]" /> </div> </div> <div class="sfs-input-group clearfix"> <div class="sfs-input-title"> Primary Driver: </div> <div class="sfs-input-wrapper"> <input type="text" name="form_data[vehicle_info][primary_driver_4]" /> </div> </div> <div class="sfs-input-group clearfix"> <div class="sfs-input-title"> Current Odometer: </div> <div class="sfs-input-wrapper"> <input type="text" name="form_data[vehicle_info][current_odometer_4]" /> </div> </div> <div class="sfs-input-group clearfix"> <div class="sfs-input-title"> Estimated Yearly Mileage: </div> <div class="sfs-input-wrapper"> <input type="text" name="form_data[vehicle_info][yearly_mileage_4]" /> </div> </div> <div class="sfs-input-group clearfix"> <div class="sfs-input-title"> Ownership: </div> <div class="sfs-input-wrapper"> <select name="form_data[vehicle_info][ownership_4]"> <option value="Not Selected">Select...</option> <option value="Owned">Owned</option> <option value="Leased">Leased</option> <option value="Financed">Financed</option> <option value="Lien">Lien</option> <option value="Loan">Loan</option> <option value="Other">Other</option> </select> </div> </div> <div class="sfs-input-group clearfix"> <div class="sfs-input-title"> Primary Use: </div> <div class="sfs-input-wrapper"> <select name="form_data[vehicle_info][use_4]"> <option value="Not Selected">Select...</option> <option value="Business">Business</option> <option value="Farming">Farming</option> <option value="Pleasure">Pleasure</option> <option value="To/From Work">To/From Work</option> <option value="To/From School">To/From School</option> </select> </div> </div> <div class="sfs-input-group clearfix"> <div class="sfs-input-title"> Anti Theft Features: </div> <div class="sfs-input-wrapper"> <select size="5" multiple="multiple" name="form_data[vehicle_info][anti_theft_features_4][]"> <option value="Not Selected">Select...</option> <option value="None">None</option> <option value="Alarm ">Alarm </option> <option value="Vehicle Recovery System">Vehicle Recovery System</option> <option value="VIN Etching">VIN Etching</option> <option value="Other">Other</option> </select> </div> </div> <div class="sfs-input-group clearfix"> <div class="sfs-input-title"> Passive Restraints: </div> <div class="sfs-input-wrapper"> <select size="5" multiple="multiple" name="form_data[vehicle_info][passive_restraints_4][]"> <option value="Not Selected">Select...</option> <option value="None">None</option> <option value="Automatic Seatbelts ">Automatic Seatbelts </option> <option value="Driver Side Airbag">Driver Side Airbag</option> <option value="Passenger Airbag">Passenger Airbag</option> <option value="Side Curtain Airbag">Side Curtain Airbag</option> <option value="Other">Other</option> </select> </div> </div> <div class="sfs-input-group clearfix"> <div class="sfs-input-title"> Anti-Lock Brakes: </div> <div class="sfs-input-wrapper"> <select name="form_data[vehicle_info][Anti-Lock_brakes_4]"> <option value="Not Selected">Select...</option> <option value="Yes">Yes</option> <option value="No">No</option> </select> </div> </div> <div class="sfs-input-group clearfix"> <div class="sfs-input-title"> Daytime Running Lights: </div> <div class="sfs-input-wrapper"> <select name="form_data[vehicle_info][daytime_running_lights_4]"> <option value="Not Selected">Select...</option> <option value="Yes">Yes</option> <option value="No">No</option> </select> </div> </div> <div class="sfs-input-group clearfix"> <div class="sfs-input-title"> Any Prior Damage to Vehicle? </div> <div class="sfs-input-wrapper"> <select name="form_data[vehicle_info][prior_damage_4]"> <option value="Not Selected">Select...</option> <option value="No">No</option> <option value="Yes">Yes</option> </select> </div> </div> <div class="sfs-input-group clearfix"> <div class="sfs-input-title"> Vehicle Ever Used for Deliveries? </div> <div class="sfs-input-wrapper"> <select name="form_data[vehicle_info][used_for_delivery_4]"> <option value="Not Selected">Select...</option> <option value="No">No</option> <option value="Yes">Yes</option> </select> </div> </div> <div class="sfs-input-group clearfix"> <div class="sfs-input-title"> Comprehensive Deductible: </div> <div class="sfs-input-wrapper"> <select name="form_data[vehicle_info][comprehensive_deductible_4]"> <option value="Not Selected">Select...</option> <option value="No Coverage">No Coverage</option> <option value="0">0</option> <option value="50">50</option> <option value="100">100</option> <option value="200">200</option> <option value="250">250</option> <option value="500">500</option> <option value="1000">1000</option> </select> </div> </div> <div class="sfs-input-group clearfix"> <div class="sfs-input-title"> Collision Deductible: </div> <div class="sfs-input-wrapper"> <select name="form_data[vehicle_info][collision_deductible_4]"> <option value="Not Selected">Select...</option> <option value="No Coverage">No Coverage</option> <option value="0">0</option> <option value="50">50</option> <option value="100">100</option> <option value="200">200</option> <option value="250">250</option> <option value="500">500</option> <option value="1000">1000</option> </select> </div> </div> <div class="sfs-input-group clearfix"> <div class="sfs-input-title"> Full Glass Coverage? </div> <div class="sfs-input-wrapper"> <select name="form_data[vehicle_info][collision_deductible_4]"> <option value="Not Selected">Select...</option> <option value="No">No</option> <option value="Yes">Yes</option> </select> </div> </div> <div class="sfs-input-group clearfix"> <div class="sfs-input-title"><label>Addition Effective Date:</label></div> <div class="sfs-input-wrapper"> <select name="form_data[vehicle_info][_date_add_effective_date_4][month]"> <option value="00">Month</option> <option value="01">January</option> <option value="02">February</option> <option value="03">March</option> <option value="04">April</option> <option value="05">May</option> <option value="06">June</option> <option value="07">July</option> <option value="08">August</option> <option value="09">September</option> <option value="10">October</option> <option value="11" selected="selected">November</option> <option value="12">December</option> </select> <select name="form_data[vehicle_info][_date_add_effective_date_4][day]"> <option value="00">Day</option> <option value="01">01</option> <option value="02">02</option> <option value="03">03</option> <option value="04">04</option> <option value="05">05</option> <option value="06">06</option> <option value="07">07</option> <option value="08">08</option> <option value="09">09</option> <option value="10">10</option> <option value="11">11</option> <option value="12">12</option> <option value="13">13</option> <option value="14">14</option> <option value="15">15</option> <option value="16">16</option> <option value="17">17</option> <option value="18">18</option> <option value="19">19</option> <option value="20">20</option> <option value="21">21</option> <option value="22">22</option> <option value="23">23</option> <option value="24">24</option> <option value="25">25</option> <option value="26">26</option> <option value="27">27</option> <option value="28">28</option> <option value="29">29</option> <option value="30" selected="selected">30</option> <option value="31">31</option> </select> <select name="form_data[vehicle_info][_date_add_effective_date_4][year]"> <option value="0000">Year</option> <option value="2024" selected="selected">2024</option> <option value="2025">2025</option> <option value="2026">2026</option> <option value="2027">2027</option> </select> </div> </div> </fieldset> </div> <div id="divNumber_of_Vehicles5" style="display:none"> <fieldset class="sfs-fieldset"> <caption align="top"> <h4>Vehicle 5</h4> </caption> <div class="sfs-input-group clearfix"> <div class="sfs-input-title"> Vehicle 5 Year: </div> <div class="sfs-input-wrapper"> <input type="text" name="form_data[vehicle_info][year_5]" /> </div> </div> <div class="sfs-input-group clearfix"> <div class="sfs-input-title"> Vehicle 5 Make: </div> <div class="sfs-input-wrapper"> <input type="text" name="form_data[vehicle_info][make_5]" /> </div> </div> <div class="sfs-input-group clearfix"> <div class="sfs-input-title"> Vehicle 5 Model: </div> <div class="sfs-input-wrapper"> <input type="text" name="form_data[vehicle_info][model_5]" /> </div> </div> <div class="sfs-input-group clearfix"> <div class="sfs-input-title"> Vehicle 5 VIN: </div> <div class="sfs-input-wrapper"> <input type="text" name="form_data[vehicle_info][VIN_5]" /> </div> </div> <div class="sfs-input-group clearfix"> <div class="sfs-input-title"> Primary Driver: </div> <div class="sfs-input-wrapper"> <input type="text" name="form_data[vehicle_info][primary_driver_5]" /> </div> </div> <div class="sfs-input-group clearfix"> <div class="sfs-input-title"> Current Odometer: </div> <div class="sfs-input-wrapper"> <input type="text" name="form_data[vehicle_info][current_odometer_5]" /> </div> </div> <div class="sfs-input-group clearfix"> <div class="sfs-input-title"> Estimated Yearly Mileage: </div> <div class="sfs-input-wrapper"> <input type="text" name="form_data[vehicle_info][yearly_mileage_5]" /> </div> </div> <div class="sfs-input-group clearfix"> <div class="sfs-input-title"> Ownership: </div> <div class="sfs-input-wrapper"> <select name="form_data[vehicle_info][ownership_5]"> <option value="Not Selected">Select...</option> <option value="Owned">Owned</option> <option value="Leased">Leased</option> <option value="Financed">Financed</option> <option value="Lien">Lien</option> <option value="Loan">Loan</option> <option value="Other">Other</option> </select> </div> </div> <div class="sfs-input-group clearfix"> <div class="sfs-input-title"> Primary Use: </div> <div class="sfs-input-wrapper"> <select name="form_data[vehicle_info][use_5]"> <option value="Not Selected">Select...</option> <option value="Business">Business</option> <option value="Farming">Farming</option> <option value="Pleasure">Pleasure</option> <option value="To/From Work">To/From Work</option> <option value="To/From School">To/From School</option> </select> </div> </div> <div class="sfs-input-group clearfix"> <div class="sfs-input-title"> Anti Theft Features: </div> <div class="sfs-input-wrapper"> <select size="5" multiple="multiple" name="form_data[vehicle_info][anti_theft_features_5][]"> <option value="Not Selected">Select...</option> <option value="None">None</option> <option value="Alarm ">Alarm </option> <option value="Vehicle Recovery System">Vehicle Recovery System</option> <option value="VIN Etching">VIN Etching</option> <option value="Other">Other</option> </select> </div> </div> <div class="sfs-input-group clearfix"> <div class="sfs-input-title"> Passive Restraints: </div> <div class="sfs-input-wrapper"> <select size="5" multiple="multiple" name="form_data[vehicle_info][passive_restraints_5][]"> <option value="Not Selected">Select...</option> <option value="None">None</option> <option value="Automatic Seatbelts ">Automatic Seatbelts </option> <option value="Driver Side Airbag">Driver Side Airbag</option> <option value="Passenger Airbag">Passenger Airbag</option> <option value="Side Curtain Airbag">Side Curtain Airbag</option> <option value="Other">Other</option> </select> </div> </div> <div class="sfs-input-group clearfix"> <div class="sfs-input-title"> Anti-Lock Brakes: </div> <div class="sfs-input-wrapper"> <select name="form_data[vehicle_info][Anti-Lock_brakes_5]"> <option value="Not Selected">Select...</option> <option value="Yes">Yes</option> <option value="No">No</option> </select> </div> </div> <div class="sfs-input-group clearfix"> <div class="sfs-input-title"> Daytime Running Lights: </div> <div class="sfs-input-wrapper"> <select name="form_data[vehicle_info][daytime_running_lights_5]"> <option value="Not Selected">Select...</option> <option value="Yes">Yes</option> <option value="No">No</option> </select> </div> </div> <div class="sfs-input-group clearfix"> <div class="sfs-input-title"> Any Prior Damage to Vehicle? </div> <div class="sfs-input-wrapper"> <select name="form_data[vehicle_info][prior_damage_5]"> <option value="Not Selected">Select...</option> <option value="No">No</option> <option value="Yes">Yes</option> </select> </div> </div> <div class="sfs-input-group clearfix"> <div class="sfs-input-title"> Vehicle Ever Used for Deliveries? </div> <div class="sfs-input-wrapper"> <select name="form_data[vehicle_info][used_for_delivery_5]"> <option value="Not Selected">Select...</option> <option value="No">No</option> <option value="Yes">Yes</option> </select> </div> </div> <div class="sfs-input-group clearfix"> <div class="sfs-input-title"> Comprehensive Deductible: </div> <div class="sfs-input-wrapper"> <select name="form_data[vehicle_info][comprehensive_deductible_5]"> <option value="Not Selected">Select...</option> <option value="No Coverage">No Coverage</option> <option value="0">0</option> <option value="50">50</option> <option value="100">100</option> <option value="200">200</option> <option value="250">250</option> <option value="500">500</option> <option value="1000">1000</option> </select> </div> </div> <div class="sfs-input-group clearfix"> <div class="sfs-input-title"> Collision Deductible: </div> <div class="sfs-input-wrapper"> <select name="form_data[vehicle_info][collision_deductible_5]"> <option value="Not Selected">Select...</option> <option value="No Coverage">No Coverage</option> <option value="0">0</option> <option value="50">50</option> <option value="100">100</option> <option value="200">200</option> <option value="250">250</option> <option value="500">500</option> <option value="1000">1000</option> </select> </div> </div> <div class="sfs-input-group clearfix"> <div class="sfs-input-title"> Full Glass Coverage? </div> <div class="sfs-input-wrapper"> <select name="form_data[vehicle_info][collision_deductible_5]"> <option value="Not Selected">Select...</option> <option value="No">No</option> <option value="Yes">Yes</option> </select> </div> </div> <div class="sfs-input-group clearfix"> <div class="sfs-input-title"><label>Addition Effective Date:</label></div> <div class="sfs-input-wrapper"> <select name="form_data[vehicle_info][_date_add_effective_date_5][month]"> <option value="00">Month</option> <option value="01">January</option> <option value="02">February</option> <option value="03">March</option> <option value="04">April</option> <option value="05">May</option> <option value="06">June</option> <option value="07">July</option> <option value="08">August</option> <option value="09">September</option> <option value="10">October</option> <option value="11" selected="selected">November</option> <option value="12">December</option> </select> <select name="form_data[vehicle_info][_date_add_effective_date_5][day]"> <option value="00">Day</option> <option value="01">01</option> <option value="02">02</option> <option value="03">03</option> <option value="04">04</option> <option value="05">05</option> <option value="06">06</option> <option value="07">07</option> <option value="08">08</option> <option value="09">09</option> <option value="10">10</option> <option value="11">11</option> <option value="12">12</option> <option value="13">13</option> <option value="14">14</option> <option value="15">15</option> <option value="16">16</option> <option value="17">17</option> <option value="18">18</option> <option value="19">19</option> <option value="20">20</option> <option value="21">21</option> <option value="22">22</option> <option value="23">23</option> <option value="24">24</option> <option value="25">25</option> <option value="26">26</option> <option value="27">27</option> <option value="28">28</option> <option value="29">29</option> <option value="30" selected="selected">30</option> <option value="31">31</option> </select> <select name="form_data[vehicle_info][_date_add_effective_date_5][year]"> <option value="0000">Year</option> <option value="2024" selected="selected">2024</option> <option value="2025">2025</option> <option value="2026">2026</option> <option value="2027">2027</option> </select> </div> </div> </fieldset> </div> </div> <fieldset class="sfs-fieldset"> <div class="sfs-input-group clearfix"> <div class="sfs-input-title"><label>Agent Name (Optional): </label></div> <div class="sfs-input-wrapper"><input name="form_data[additional_information][agent]" value="" type="text" size="30" /></div> </div> <div class="sfs-input-group clearfix"> <input type="hidden" name="token" value="11177a05a9937d3fa7e5fe4738752edd" /> <input type="hidden" name="step" value="1" /> <div style="text-align:center; padding:10px 0"><input class="btn btn-success g-recaptcha" type="submit" name="finish" value="Submit" data-sitekey="6LfRl8IZAAAAACbxaSQmUwN4BWefaYIj6gMQBmiR" data-callback='submitFinish' /></div> </div> </fieldset> </form> </div> <div id="disclaimer_div" class="fine_print"> Website Disclaimer - Review Carefully:<br /><br /> This is a solicitation for insurance. <strong>Insurance coverage cannot be bound or changed via submission of this online form/application, e-mail, voicemail 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.</strong> 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. </div> </div></div></div></main></div></div></div><div class="carriers-scroll"></div><footer><div class="container"><div class="visible-xs"><div class="social-nav-container"><a href="https://www.facebook.com/ParagonInsuranceOKC/" target="_blank" aria-label="Visit Facebook (opens in a new tab)"><em class="fa fa-facebook"></em><span class="sr-only">Facebook</span></a><a href="https://twitter.com/paragonokc" target="_blank" aria-label="Visit Twitter (opens in a new tab)"><em class="fa fa-twitter"><span class="sr-only">Twitter</span></em></a><a href="https://www.linkedin.com/company/paragonokc/" target="_blank" aria-label="Visit LinkedIn (opens in a new tab)"><em class="fa fa-linkedin"></em><span class="sr-only">LinkedIn</span></a><a href="https://www.yelp.com/biz/paragon-insurance-piedmont" target="_blank" aria-label="Visit Yelp (opens in a new tab)"><em class="fa fa-yelp"></em><span class="sr-only">Yelp</span></a><a href="https://https://www.instagram.com/paragonokc/" target="_blank" aria-label="Visit Instagram (opens in a new tab)"><em class="fa fa-instagram"></em><span class="sr-only">Instagram</span></a></div></div><div class="row columns hidden-xs"><div class="hidden-xs col-sm-3"><ul><li class="footer-column-first"><a href="customer-resources/sitemap" aria-label="Site Map">Navigation</a></li><li><a href="https://paragonokc.com/">Home</a></li><li><a href="https://paragonokc.com/about">About</a></li><li><a href="https://paragonokc.com/online-insurance-quotes">Quote Request</a></li><li><a href="https://paragonokc.com/customer-support">Support</a></li><li><a href="https://paragonokc.com/customer-resources">Resources</a></li><li><a href="https://paragonokc.com/customer-support/payments-and-claims">Payments & Claims</a></li><li><a href="https://paragonokc.com/customer-resources/insurance-companies">Our Companies</a></li><li><a href="https://paragonokc.com/blog">Blog</a></li><li><a href="https://paragonokc.com/contact">Contact</a></li><li><a href="https://paragonokc.com/customer-resources/privacy">Privacy Policy Statement</a></li></ul></div><div class="col-sm-3"><ul><li class="footer-column-first"><a href="personal-insurance" aria-label="Personal">Personal Lines</a></li><li><a href="https://paragonokc.com/personal-insurance/home-insurance">Homeowners Insurance</a></li><li><a href="https://paragonokc.com/personal-insurance/car-insurance">Auto Insurance</a></li><li><a href="https://paragonokc.com/personal-insurance/individual-life-insurance">Individual Life Insurance</a></li><li><a href="https://paragonokc.com/personal-insurance/motorcycle-insurance">Motorcycle Insurance</a></li><li><a href="https://paragonokc.com/personal-insurance/mobile-home-insurance">Manufactured / Mobile Home</a></li><li><a href="https://paragonokc.com/personal-insurance/atv-insurance">ATV</a></li><li><a href="https://paragonokc.com/personal-insurance/boat-insurance">Boat & Watercraft</a></li><li><a href="https://paragonokc.com/personal-insurance/condo-insurance">Condo Insurance</a></li><li><a href="https://paragonokc.com/personal-insurance/earthquake-insurance">Earthquake</a></li><li><a href="https://paragonokc.com/personal-insurance/flood-insurance">Flood Insurance</a></li></ul></div><div class="col-sm-3"><ul><li class="footer-column-first"><a href="business-insurance" aria-label="Business">Commercial Lines</a></li><li><a href="https://paragonokc.com/business-insurance/commercial-auto-insurance">Commercial Auto</a></li><li><a href="https://paragonokc.com/business-insurance/commercial-property-insurance">Commercial Property</a></li><li><a href="https://paragonokc.com/business-insurance/builders-risk-insurance">Builders Risk</a></li><li><a href="https://paragonokc.com/business-insurance/business-owners-policy">Business Owners Policy (BOP)</a></li><li><a href="https://paragonokc.com/business-insurance/condo-assoc-owners-insurance">Condo Association</a></li><li><a href="https://paragonokc.com/business-insurance/apartment-building-insurance">Apartment Building Owners</a></li><li><a href="https://paragonokc.com/business-insurance/church-insurance">Church Insurance</a></li><li><a href="https://paragonokc.com/business-insurance/agri-business">Agribusiness</a></li><li><a href="https://paragonokc.com/business-insurance/bond-insurance">Bonds</a></li><li><a href="https://paragonokc.com/business-insurance/commercial-umbrella-insurance">Commercial Umbrella</a></li></ul></div><div class="col-sm-3"><ul><li class="footer-column-first"><a href="online-insurance-quotes" aria-label="Quote Request">Quote Request Forms</a></li><li><a href="https://secureformsolutions.com/form/paragonokc.com/apartmentowners" target="_self" aria-label="Apartment Building Owners">Apartment Building Owners</a></li><li><a href="https://secureformsolutions.com/form/paragonokc.com/boat" target="_self" aria-label="Boat & Watercraft">Boat & Watercraft</a></li><li><a href="https://secureformsolutions.com/form/paragonokc.com/bonds" target="_self" aria-label="Bonds">Bonds</a></li><li><a href="https://secureformsolutions.com/form/paragonokc.com/builders_risk" target="_self" aria-label="Builders Risk">Builders Risk</a></li><li><a href="https://secureformsolutions.com/form/paragonokc.com/business" target="_self" aria-label="Business Owners Policy (BOP)">Business Owners Policy (BOP)</a></li><li><a href="https://secureformsolutions.com/form/paragonokc.com/church" target="_self" aria-label="Church Insurance">Church Insurance</a></li><li><a href="https://secureformsolutions.com/form/paragonokc.com/commauto" target="_self" aria-label="Commercial Auto">Commercial Auto</a></li><li><a href="https://secureformsolutions.com/form/paragonokc.com/comm_building" target="_self" aria-label="Commercial Property">Commercial Property</a></li><li><a href="https://secureformsolutions.com/form/paragonokc.com/condo" target="_self" aria-label="Condo Association">Condo Association</a></li><li><a href="https://secureformsolutions.com/form/paragonokc.com/condominium" target="_self" aria-label="Condo Insurance">Condo Insurance</a></li></ul></div></div><div class="row"><div class="col-xs-12"><div class="contact-horizontal">13100 Colony Pointe Blvd, Ste 107 Piedmont, OK 73078 | <strong>Phone: <a href="tel:4052839250" class="phone-link">405-283-9250</a></strong> | <a href="https://secureformsolutions.com/form/paragonokc.com/contact" aria-label="Secure Contact Form">Contact Us</a> | <a href="https://paragonokc.com/contact">Get Map</a><div class="centered line_pad">1133 N Kickapoo Ave Shawnee, OK 74801| <strong>Phone: 405-695-5103</strong> | <a href="https://secureformsolutions.com/form/paragonokc.com/contact" aria-label="Secure Contact Form">Contact Us</a> | <a href="https://paragonokc.com/contact/557">Get Map</a></div></div></div></div><div class="row"><div class="col-xs-12"><div class="footer-cities">Located in <a href="contact">Piedmont, Oklahoma</a>; <a href="https://paragonokc.com/contact/557">Shawnee, Oklahoma</a>. We also serve the Edmond, El Reno, Mustang, Oklahoma City, and Yukon areas. - Licensed in Oklahoma</div></div></div><div class="row"><div class="col-xs-12"><div class="footer-copyright">Site by: <a href="https://alicorsolutions.com/" target="_blank" aria-label="Visit Alicor Solutions (opens in a new tab)">AlicorSolutions.com</a> &bullet; © 2024 Paragon Insurance</div></div></div></div></footer></div><script src="https://ajax.googleapis.com/ajax/libs/jquery/1.12.4/jquery.min.js"></script> <script src="https://ajax.googleapis.com/ajax/libs/jqueryui/1.12.1/jquery-ui.min.js"></script> <script> $(function() { $( ".datepicker" ).datepicker(); }); </script> <script src="https://maxcdn.bootstrapcdn.com/bootstrap/3.3.4/js/bootstrap.min.js"></script><script src="https://alicorsolutions.com/scripts/4.2/js/jssor.slider.mini.js"></script><script> var jsOptions = { SlideDuration: 750, AutoPlayInterval: 3250, Fade: false, ArrowNavigatorOptions: { AutoCenter: 2 }, BulletNavigatorOptions: { AutoCenter: 1 }, }; </script><script src="https://alicorsolutions.com/scripts/4.0/js/skrollr.js"></script> <script> $(document).ready(function(){ if(!(/Android|iPhone|iPad|iPod|BlackBerry|Windows Phone/i).test(navigator.userAgent || navigator.vendor || window.opera)){ skrollr.init({ forceHeight: false }); } var stickyNavTop; var setHeaderHeight = function() { $('header.masthead').removeClass('fixed'); $('.header-wrapper').css('height', 'auto'); stickyNavTop = $('.header-wrapper').height(); $('.header-wrapper').css('height', stickyNavTop); } /** STICKY NAV **/ var stickyNav = function() { var scrollTop = $(window).scrollTop(); if (scrollTop > stickyNavTop) { if (! $('header.masthead').hasClass('fixed')) { $('header.masthead').hide().addClass('fixed').slideDown(250); //stickyNavTop = $('.top-content').height(); //$('.top-wrapper').css('height', stickyNavTop); //$('.masthead').hide().addClass('fixed').slideDown(); } } else { $('header.masthead').removeClass('fixed'); //stickyNavTop = $('.top-content').height(); //$('.top-wrapper').css('height', stickyNavTop); } }; setHeaderHeight(); stickyNav(); $(window).scroll(function() { stickyNav(); }); $(window).resize(function() { setHeaderHeight(); }); $('.qq-sticky-button').click(function(e) { var $container = $('.qq-sticky-container'); if ($container.hasClass('open')) { $container.removeClass('open').animate({ right: "0" }, 1000); } else { $container.addClass('open').animate({ right: "400px" }, 1000); } }); }); </script><script src="https://alicorsolutions.com/scripts/4.2/js/shared.js"></script><script src="design/1810/script.js"></script></body></html>

CINXE.COM

Remove Vehicle Request Form