Add Vehicle

This form will allow you to add a vehicle to an existing DTRIC Insurance auto policy. Please be prepared to provide a copy of your vehicle registration.

Fields marked with an asterisk (*) are required

__ Policyholder Information

*First Name
*Last Name
Middle Name
E-Mail Address
Home Phone
Work Phone
Fax Number
Best way to contact you

Best time of the day to contact you
*Street Address Line 1
Street Address Line 2


*State, *Zipcode


*Policy Number

__ Vehicle Information

Please check a "Vehicle Number" box before entering information in the corresponding column.
Cost (if newly purchased) $
*Body Type
*Vehicle ID Number (VIN)
*How is the vehicle used?
*How many days per week?
*What island is the vehicle garaged on?
*Name of the registered owner of this vehicle
*Name of the most frequent operator of this vehicle
*Date at which you wish to add this vehicle (mm/dd/yyyy)
__ Financial Ownership Information
Vehicle #1
Vehicle #2
Vehicle #3
Is the vehicle being financed?
If "yes," complete the sections below.
Is the vehicle Leased or Financed?
Institution Name
Address Line 1
Address Line 2
__ Additional Insured Information (Leasing Company)
Complete this section only if vehicle is leased.
Vehicle #1
Vehicle #2
Vehicle #3
Name of Additional Insured
Institution Name
Mailing Address Line 1
Mailing Address Line 2
__ Policy Coverages
The following coverage limits marked with an asterisk (*) below are required by Hawaii State Insurance Law. Please note that they apply to ALL of the vehicles on your policy.
*Bodily Injury
*Property Damage
*Personal Injury Protection (PIP)
*PIP Deductible
PIP Co-Pay Deductible
Uninsured Motorist Coverage (UM)
Underinsured Motorists (UIM)
Wage Loss Benefits
Death Benefits Coverage
Funeral Expense Coverage
Alternative Care Coverage
__ Personal Auto Per-Vehicle Coverages
Vehicle #1
Vehicle #2
Vehicle #3
Other Than Collision
Towing Coverage
Extended Transportation
Please note that not all Rental Reimbursement Limit options are available in your auto plan. If you select this coverage, we will provide the best limit that is available unless you specify otherwise.
__ Questions Concerning Your Vehicles

Please review the following set of questions. Leave them blank if the question does not apply to you or if your answer to the question is NO. Otherwise, please provide a brief explanation or comment in the space provided.

1. Have any of your vehicles been customized with special equipment, accessories or furnishings? If so, please specify which vehicles and the kinds of equipment involved.
2. Have any of your vehicles been physically altered or enhanced since original purchase from the dealership? Please specify the vehicle(s) and the type of alteration(s).
3. Are any vehicles garaged at a location other than your residence?
4. Are any vehicles rebuilt or repaired from a prior accident?
5. Were any vehicles uninsured prior to adding it to your policy?
6. Are there any existing damages to your vehicles?

Thank you for completing this DTRIC Insurance vehicle addition form.
We will contact you within two business days of this request.

Submitting this form does not bind or change insurance coverage until
the information is verified by both the insured and DTRIC or your DTRIC agent.

If you do not agree to the terms and conditions of use for this form, your information will not be submitted to DTRIC Insurance. Please call a service representative at 944-5400 or 1-888-944-5474 (Neighbor Islands, toll free) or you can call your agent.