"*" 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.Current Vehicle To Be Updated (1)*Please note the year, make & model of the car you would like coverage changed on. If you want this change on the ENTIRE POLICY, please note: PolicyCurrent Vehicle To Be Updated (2)Please note the year, make & model of the car you would like coverage changed on. Leave this blank if it applies to only 1 car. Add or Remove Personal Injury Protection Add - Personal Injury Protection or Medical Payments Remove - Personal Injury Protection or Medical Payments This is a policy-wide coverage and will apply to all vehicles. ADD: If you are adding Personal Injury Protection or Medical Payments, we will include the limit of $10,000. If you prefer the $35,000 option, please note that in the comments. REMOVE: If you are removing PIP from your policy, we will be sending an additional form, to your email, to esign. WHAT IS Personal Injury Protection: PIP is a not-fault insurance that covers medical expenses, lost wages and other related costs resulting from a car accident. *https://www.insurance.wa.gov/personal-injury-protection-pipRemove Vehicle Coverage Comprehensive - theft, fire, vandalism, falling objects, glass, hitting an animal Collision - physical damage to your car if you hit a car or object Rental Car - help renting a car if you're vehicle is not drivable after a covered loss Roadside Assistance - towing, fluid, flat repair, lock out This request is to remove coverage from the vehicle(s) listed above. Note: If Collision is removed, it will also remove Comprehensive and Rental Car. However, you can leave Comprehensive without Collision. Comments/Additional NotesThank you for using our online form! If you have any additional notes, questions or comments, please note them here. *NOTE: One of our team members will send you a confirmation (or follow up with additional questions) within 24-48 business hours. Email Confirmation If you would like a confirmation of this request and an email confirmation once the change is processed, please add your email address here. Text ConfirmationIf you would like to receive a text confirmation once the change is processed, please enter your mobile number here. Your Name (Who is filling out this form?)*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. Authorization: By SUBMITTING this form, you are confirming you are aware you are reducing or removing material coverages from your insurance. Yes No Approval & Verification: By SUBMITTING this form, are you confirming the information you provided is true and accurate?* Yes No By selecting the SUBMIT button, are you confirming that the information you provided is true and accurate?
