ChamberCare - Chamber Member Discount Plans

This form is provided for your convenience. Your change is not bound until confirmed by our office. We will respond to you within 1 to 2 business days. If you have not received confirmation within 1 to 2 business days, please call our office during regular business hours at 608-837-2484.

Your Name:	First: Middle Initial: Last:
Address:	Street: City: State: Zip:   , WI
Phone Number:	( ) -
Email Address:
Change Vehicle
	Add Delete Vehicle 1 Vehicle 2 Vehicle 1 Vehicle 2
Effective Date: (Example: 01/31/2001)
Make - Model:
Year:
Vehicle ID (VIN):
Leinholder Name & Address:
Car Usage:	Work/School Pleasure Work/School Pleasure
Miles One Way (Work/School):
Liability Limits
	Vehicle 1 Vehicle 2
Bodily Injury:	100/300 150/300 250/500 100/300 150/300 250/500
Property Damage:	100,000 250,000 100,000 250,000
Single Limit:	300,000 500,000 300,000 500,000
Deductables & Coverages
	Vehicle 1 Vehicle 2
Comprehensive Deductable:	$100 $250 $500 $1000 $100 $250 $500 $1000
Collision Deductable:	$100 $250 $500 $1000 $100 $250 $500 $1000
Towing:	Yes No Yes No
Rental Reimbursement:	Yes No Yes No
New Driver Information
	Driver 1 Driver 2
Full Name:
License #:
License State:
Date of Birth:
Primary Vehicle Used: (Make/Model/Year)
Comments:

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804 Liberty Blvd. Suite 203 • Sun Prairie, WI 53590 • 608.837.2484 • info@harmsinsurancegroup.com