Nation Motor Club Membership Application

3900 W. Commercial Blvd., Suite 200, Ft. Lauderdale, Florida 33309

Applicant Name :
Applicant Address :
City : State: Zip:
Home Phone #: Office Phone #:
Cellular Phone #: Fax Phone #:

How would you like to pay?

Vehicle One: Year:
Make:
Model:
Color:
ID #: Plate #:

Vehicle Two: Year:
Make:
Model:
Color:
ID #: Plate #:

Vehicle Three: Year:
Make:
Model:
Color:
ID #: Plate #:

Producer: Stephen P. Cyganik, a licensed Casualty Insurance Agent since 1973.

Fill out application and return with check, money
order or credit card with account number and
expiration date.

This contract will go into effect when application is
received, at which time you will receive confirmation.

Producer provides a 20% discount for each limousine
or sedan that is claim-free during the first year, upon
renewal.

Your cost is $75 per Limousine or Sedan

Additional limousines or sedans discounted $10 each

This contract covers you for one year

FOR CLAIMS INFORMATION:

(The average claim has a 7 day turnaround.)

757-595-2945
1-800-879-LIMO

Mail Application and Payment to:

Nation Motor Club, Inc.
9314 Warwick Boulevard
Newport News, Virginia 23601

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Last Updated November 11, 1996 by Nation Motor Club