Auto Change Request Changes to MakePlease indicate the changes to be made* Update Address, Phone, etc Add a Vehicle Remove a Vehicle Add a Driver Remove a Driver Change Coverages on Vehicle Update Car Loan Info Other (Use Additional Info box) Policy Holder InformationPolicy Holder Name* First Last Name of person requesting change*Policy # (if known)Confirmation Preference*Text MessagePhoneEmailNoneConfirmation Phone/Email*Confirmation NoteQuote Only or Process Change ASAP* Quote Only Process Change ASAP (if possible) CSR (if done in-agency)Requested Effective Date* MM slash DD slash YYYY Contact InformationStreet Address (only if change)City, State, Zip (only if change)Mailing Address (only if change)Mailing City, State, Zip (only if change)Policy Holder Phone (only if change)Policy Holder Email (only if change) Add a DriverName of Driver to be Added* First M Initial Last Does this person live at your address?* Yes No How long have they lived with you?*Where do they live?*What is their relationship to you?*Select OneChildSpouseSignificant OtherParentRoomateFriendOtherMarital Status*SingleMarriedDivorcedSeparatedWidowedWho are they?*Driver's Date of Birth* MM slash DD slash YYYY Gender*ChooseMaleFemaleDriver's License Number & State*Years Licensed*Is the new driver a full-time student?* Yes No Does he/she have a 3.0 GPA or higher?* Yes No 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.Get the DiscountThe Good Student Discount will be applied to your account once we receive a copy of the report card or transcript.Do you want to upload a copy of the report card now?* Yes No, I'll send it in later Upload Report Card*Max. file size: 128 MB.Remove a DriverName of Driver to be Removed* First Last Driver's Date of Birth* MM slash DD slash YYYY Reason for Removal* No Longer In Household Away at College In the Military On a Mission Has Own Insurance Other Where do they now live & when did they move?*Where are they going to school? How long will they be gone? and how often will they come home during the year?*How long will they be gone? and how often will they come home during the year?*How long will they be gone?*Do they still live at your house? and When did they start their policy?*Please explain*Add a VehicleYear, Make, & Model of Vehicle*VIN*Verify the VIN by using: vinCheck, AutoDNA, or SearchQuarry Who is the vehicle registered to?*Who is primary driver of vehicle?*Date Purchased (approximate)*Comprehensive Deductible*Select OneNo Comp Coverage$100$250$500$1,000Same as other vehiclesCollision Deductible*Select OneNo Collision Coverage$100$250$500$1,000Same as other vehiclesWhen adding Comprehensive & Collision (what the banks call Full Coverage) we may need photos of the vehicle. If you just purchased from a dealership, we may be able to use a copy of the bill of sale instead. Please email photos from each corner ( to the agency or upload them using the "Send Documents" button below. Email address: [email protected] Does this vehicle have any non-stock/special equipment?* Yes No Describe all non-stock/special equipment*Describe all non-stock/special equipmentDoes this vehicle have any existing damage?* Yes No Describe all existing damage*Describe any existing damageVehicle Use* Commute to work or school Pleasure Business Miles Driven each way*Estimated Miles Driven Per Year*Describe Business Use*Is this vehicle used for Rideshare (Uber, Lyft, etc.)?* Yes No Is this vehicle used for any kind of delivery (Newspaper,Pizza, etc.)?* Yes No Do you want to Uninsured Motorist added (if not already on policy)?* No Change - Same coverage as other cars Yes - Add it if not already on polcy Do you want Personal Injury Protection coverage added (if not already on policy)?* No Change - Same coverage as other cars Yes - Add it if not already on policy Do you want Rental Car reimbursement coverage? (if available)* Same as other car(s) Yes No Do you want Roadside Assistance Coverage (Towing)? (if available)* Same as other car(s) Yes No Lien holder Information* I have a loan on this vehicle This vehicle is leased There is no loan or lease on this vehicle Bank or Credit Union name:*Lease Company Name*Are you interested in GAP coverage? (if available)* Yes No Remove a VehicleYear, Make, & Model of Vehicle*Reason for Removal* Traded In Sold Not Operational Parked Selling Vehicle Some companies may require a written request to remove a vehicle. If required, we will text you asking you to reply to confirm the removal or your can write out the request and send it to us by email or attach it below where it says: "Send Documents". 👉We will not be able to process the change until we receive confirmation.Update Car Loan InfoCar Loan Update Type* Current Loan - bank or credit union needs proof of insurance New loan - update policy and send proof of insurance Loan Paid off - Remove Lien Holder info Year, Make, & Model of Vehicle*Finance Company Name*Account # (if needed)Finance Company FaxFinance Company Email Upload Car Loan InfoMax. file size: 128 MB.Change Coverages on an Vehicle Currently on PolicyIf we are removing or lowering coverages (higher deductibles), the company will require a signed request. If we are adding or increasing coverage (lower deductibles), the company will require photos of the vehicle. You can wait for the form to be e-mailed to you for e-signature or you may upload it using the "upload" button near the bottom of this form. 👉We will not be able to process the change until we receive confirmation.Year, Make, & Model of Vehicle*What Changes do you want to make?* Change Comprehensive Deductible Change Collision Deductible Change Liability Limits Change Personal Injury Protection (PIP) Change Uninsured Motorist (UM) Change Roadside Service Change Rental Car Reimbursement overage New Comprehensive Deductible*Select OneNo Coverage$100$250$500$1,000New Collision Deductible*Select OneNo Coverage$100$250$500$1,000New Liability Limits*Select OneNo Coverage (garaged vehicles)25/50/2550/100/50100/300/100250/500/250New PIP Limits*Select OneNone10,00035,000New UM Limits*Select OneNoneMatch Liability LimitsRoadside Service*Select OneRemove Roadside CoverageAdd Roadside CoverageAdd Enhanced Roadside CoverageRental Car Reimbursement*Select OneRemove Rental Car Reimbursement$20 per day$30 per day$40 per day$50 per dayAdditional Info or Other Changes RequestedSend DocumentsMax. file size: 128 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. NameThis field is for validation purposes and should be left unchanged.
