Policy Change Request Form

Person Requesting Change*

Policy Holder Name*

Email*

Phone*

Changes to Make

Please indicate the changes to be made*

Replace a Vehicle

Date Vehicle to be Replaced*

Vehicle to be Removed*

Reason for Removal*

Other

Have you returned License plates to the DMV

Yes
No

Vehicle to be Added*

VIN*

Verify the VIN by using: VehicleHistory.com , AutoDNA.com , or SearchQuarry.com

Who is the vehicle registered to?*

Vehicle Use*

Commute to Work
Pleasure
Used for Business

Note-Please provide details of busniess use

Estimated Miles Driven Per Year*

Is this Vehicle Used for Rideshare (Uber, Lyft, etc.)?*

Yes
No

Is this Vehicle Used for any kind of delivery (Uber Eats, Postmates, Pizza etc)?*

Yes
No

Does this vehicle have any existing damage?

Yes
No

The carrier will require pictures,Please upload 4 pictures

Drop files here or

Max. file size: 50 MB.

Comprehensive Deductible

(required if you have a loan/lease)

Collision Deductible

(required if you have a loan/lease)

Do you want Rental Car reimbursement coverage?*

Yes
No

Do you want Roadside Assistance Coverage?*

Yes
No

Lien holder Information

I have a loan on this vehicle
This vehicle is a lease
There is no loan or lease on this vehicle

Name of bank or finance company

Upload Vehicle Documentation

Max. file size: 50 MB.

Please upload any documentation you have about your vehicle such as a purchase contract, registration information, etc.

Additional Notes or Comments

Notice of Agreement*

I understand that no changes will go into effect until an agent has reviewed the request to make sure it complies with my insurance company's underwriting guidelines and the change has been accepted by the company.

Add a Vehicle

Date Vehicle to be Added*

Vehicle to be Added*

VIN*

Verify the VIN by using: VehicleHistory.com , AutoDNA.com , or SearchQuarry.com

Who is the vehicle registered to?*

Vehicle Use*

Commute to Work
Pleasure
Used for Business

Note-Please provide details of busniess use

Estimated Miles Driven Per Year*

Is this Vehicle Used for Rideshare (Uber, Lyft, etc.)?*

Yes
No

Is this Vehicle Used for any kind of delivery (Uber Eats, Postmates, Pizza etc)?*

Yes
No

Does this vehicle have any existing damage?

Yes
No

Please upload 4 pictures of vehicle

Drop files here or

Max. file size: 50 MB.

Comprehensive Deductible

(required if you have a loan/lease)

Collision Deductible

(required if you have a loan/lease)

Do you want Rental Car reimbursement coverage?*

Yes
No

Do you want Roadside Assistance Coverage?*

Yes
No

Lien holder Information

I have a loan on this vehicle
This vehicle is a lease
There is no loan or lease on this vehicle

Name of bank or finance company

Upload Vehicle Documentation

Max. file size: 50 MB.

Please upload any documentation you have about your vehicle such as a purchase contract, registration information, etc.

Additional Notes or Comments

Notice of Agreement*

I understand that no changes will go into effect until an agent has reviewed the request to make sure it complies with my insurance company's underwriting guidelines and the change has been accepted by the company.

Remove a Vehicle

Date Vehicle to be Removed*

Vehicle to be Removed*

Reason for Removal*

Other

Have you returned license plates to the DMV

Yes
No

Additional Notes or Comments

Notice of Agreement*

I understand that no changes will go into effect until an agent has reviewed the request to make sure it complies with my insurance company's underwriting guidelines and the change has been accepted by the company.

Add a Driver

Date Driver to be Added*

Name of Driver to be Added*

Does this person live at your address?*

Yes
No

Correct address

What is their relationship to you?*

Marital Status*

Date of Birth

Gender

Driver's License Number*

State*

All Tickets & Accidents*

Please list all tickets received (paid for or not) the last 3 years and accidents (at fault or not) the last 5 years. Type "None" if none.

Is the new driver a student?

Yes
No

Does he/she maitain a 3.0 GPA?

Yes
No

Please upload report card/transcript for possible board student dicsount

Max. file size: 50 MB.

Additional Notes or Comments

Notice of Agreement*

I understand that no changes will go into effect until an agent has reviewed the request to make sure it complies with my insurance company's underwriting guidelines and the change has been accepted by the company.

Add a Driver

Date driver to be Removed*

Name of Driver to be Removed*

First Last

Driver's Date of Birth*

Reason for Removal*

No Longer in Household
Away at College
Has Own Insurance
Other

Other

Update Car Loan Info / Lease Info

Car Loan Update Type

Current Loan/Lease - bank or credit union needs proof of insurance
New Loan/Lease - update policy and send proof of insurance
Loan Paid off - Remove Lien Holder info

Which Vehicle is the loan is associated with?

Company Name

Account # (if needed)

Company Email Address*

Change Coverages on a Vehicle

Date for Coverage Update*

Which vehicle do you want to change coverage on*

Date for Coverage Update

Change Comprehensive Deductible
Change Collision Deductible
Change Liability Limits
Change Roadside Service
Change Rental Car Reimbursement Coverage

Note-Change in coverage may require pictures

Update Mortgage Company Info

Mortgage Update Type (select all that apply)*

Loan Sold - Update Mortgage Company Info
Current Mortgage Company - Mortgage company didn't get the renewal notice
Current Mortgage Company- Home Insurance wasn't paid, send payment info
Update Mortgage Company - Home Insurance Bill not paid, send payment info
Update Mortgage Company - Send them current Home Insurance Info

Mortgage Company Name*

Account Number or Loan Number

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Fax Number

Email*

Upload Mortgage Documentation

Drop files here or

Max. file size: 50 MB.

Update / Change Address

Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Enter Updated or Changed Address. We will update the address on all policy(ies).

Additional Notes or Comments

Upload Supporting Documentation or Reports

Drop files here or

Max. file size: 50 MB.

Notice of Agreement*

I understand that no changes will go into effect until an agent has reviewed the request to make sure it complies with my insurance company's underwriting guidelines and the change has been accepted by the company.

Policy Change Requests