OPTIONAL CONTRACT
PERIODS
1 MONTH 3 MONTHS 6 MONTH 12 MONTHS 1 MONTH
(with automatic renewal)
Renewable with
any of the options
on the left and
OPTIONALLY
RENEWABLE

as long as you
own your vehicle.
POWERTRAIN
WARRANTY
 $19.07*  $54.34*  $102.97*  $194.50*  $14.59*
EXPANDED
WARRANTY
 $24.50*  $69.82*  $132.30*  $249.75*  $18.73*
*Rates apply to most vehicles, subject to underwriting guidlines.
You may apply by phone, toll-free, at (800) 225-4711.

Your Information
Customer Number:    - 
First Name:     Last Name:  
Street Address:  
City:      State/Province:      Zip Code/Postal Code:  
My phone number(s): Home #      Work #  
E-mail:  
Employer:     Position:  

Vehicle Information
Model Year:      Make:      Model:  
Current odometer reading:   ( mi km )    Annual Driving Usage:   ( mi/yr km/yr )
Is this vehicle commercially used?   yes   no  

Payment Information
Card No:      Exp. Date:     /     Verification Code:      Coupon Code:     

Consent and Agreement
I have read and agree to all the terms of the contract. Sample contracts available here or on request at (800) 225-4711.
I attest all information is true and correct.