Change Request: Vehicle 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. Client Name* First Last Change Effective Date* Please let us know the date you'd like this change(s) effective. Preferred Method of Confirmation* 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! Remove Vehicle The year, make and model for the vehicle you wish to remove. *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. Reason for Removing Vehicle What is the reason the vehicle is being removed? I.e. sold, not drive-able. N/A if not applicable. Adding Vehicle* The year, make, model for vehicle you wish to add or NONE of no vehicles are being added. VIN* Vehicle Identification Number for vehicle adding. Or N/A if not applicable. Coverages Requested*Liability Only (original policy-wide coverages)Comprehensive ($500 Deductible) - or other in comments below$0 Deductible Glass Coverage - if availableCollision ($500 Deductible) - or other in comments belowTowing/Roadside Assistance - if availableRental Car - if availableGAP - optional on some policies with LienholderN/AWe will match your existing coverage, unless other coverages are noted. Owner/ Title Holder*YesNo - details in comments belowN/AYes if you are the owner/title holder. No if there is another title holder or co-owner and relay the details in the comments below. Or N/A if not applicable. 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. Estimated Value* What is the estimated value of the vehicle. Or N/A if not applicable. Rideshare*No Rideshare UsageYes Rideshare UsageN/APlease let us know if you use your vehicle for rideshare. I.e. Uber, Lyft. Or N/A if not applicable. Garaged Location*YesNo - details in comments belowN/AYes if the vehicle is garaged at your primary residence. No, if not. Or N/A if not applicable. Annual Miles* About how many miles do you drive annually? Generally below 7500 qualifies for low mileage discounts. Or N/A if not applicable. Lienholder/Additional Interest* If there is a lienholder, leasing company or additional interest, please list them here. Or N/A if not applicable. 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.
