"*" 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. 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! 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?
