"*" indicates required fields Change Request Acceptance*I understandNo follow up neededChange Request Guidelines: Policy changes cannot be processed on a cancelled policy. Each carrier and policy has different requirements and we may be unable to backdate a request, offer requested coverage or have additional options to review. We will connect with you if your request is unable to be processed. Quote Only? No - Make this Change Yes - Quote Only If you want a QUOTE ONLY, please let us know here. Client Name / Primary Policy Holder* First Last Change Effective Date*Please let us know the date you'd like this change(s) effective. If you would like a QUOTE ONLY, please let us know in the Comments.Date of Purchase*For new purchases, when did you buy this vehicle?Current Recreational Vehicle we are Removing/ReplacingPlease note the year, make & model of the car you are removing/replacing. Leave blank if you're not removing a vehicle. *NOTE: If you still own the vehicle, there may be coverage options for "storage" that will remove the liability rate but still allow for some protection and maintaining a multi-vehicle discount. If you'd like to review those options, please add the the comments below. Adding Vehicle: Year, Make, Model*The year, make, model for vehicle you wish to add or NONE of no vehicles are being added. VIN / Serial#*Vehicle Identification Number for vehicle adding. Or N/A if not applicable. CCs*What are the CCs?Estimated Value / Full Purchase Price*What is the estimated value of the vehicle. Modified Engine to enhance performanceNoYes (details in comments)Has the engine been modified to enhance performance? Please include details in comments. Antilock Brakes Yes No Does the recreational vehicle have antilock brakes?Registered for street legal use? Yes No Will you be doing be any racing or competitions? Yes No Are You the Registered Owner?*YesNo - details in comments belowN/AYes if you are the registered owner. No if there is another owner or co-owner and add their information in the Comments below. Or N/A if not applicable. Is there any Existing Damage?*NoYes - details in comments belowN/ANo or Yes. For Yes, please describe location of body or glass damage in the comments below. Or N/A if not applicable. Will you be adding any Custom or Aftermarket Parts?*NoYes - description of parts & values in commentsN/AIf you have added any custom or aftermarket partsIs the Garaged Location Your Residence?*YesNo - details in comments belowN/AYes if the vehicle is garaged at your primary residence. No, if not, and please describe in the Comments below. Lienholder/Additional Interest*If there is a lienholder, leasing company or additional interest, please list them here. Or N/A if not applicable. Coverages Requested* Liability Only (original policy wide coverage) Comprehensive ($500 Deductible) - unless other amount in comments $0 Deductible Glass Coverage - if available Collision ($500 Deductible) - unless other amount in comments Towing/Roadside Assistance - if available Rental Car - If available GAP (Loan Coverage) - if available OEM Parts - if available Use Existing Coverage Limits We will use your existing coverage, unless other coverage options are requested here. Comments/Additional NotesThank you for using our online form! If you have any additional notes, questions or comments, please note them here. *NOTE: You will receive a confirmation or follow up with additional questions within 24-48 business hours. Preferred Method of Confirmation *Include Email Address or Phone#*Please let us know if you prefer an email or text confirmation once the change is processed. If you have new contact information, please note that. Thank you! Who is filling out this form?*Please let us know your name and/or if you are the policy holder, household member, lender or agent.Approval & Verification: By SUBMITTING this form, are you confirming the information you provided is true and accurate?*YesNoBy selecting the SUBMIT button, are you confirming that the information you provided is true and accurate?
