Auto Change Request

Changes to Make

Please 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 Information

Policy Holder Name*

First Last

Name of person requesting change*

Policy # (if known)

Confirmation Preference*

Confirmation Phone/Email*

Confirmation Note

Quote Only or Process Change ASAP*

Quote Only
Process Change ASAP (if possible)

Requested Effective Date*

CSR (if done in-agency)

Contact Information

Street 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 Driver

Name 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?*

Marital Status*

Who are they?*

Driver's Date of Birth*

Gender*

Driver'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 Discount

The 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*

Remove a Driver

Name of Driver to be Removed*

First Last

Driver's Date of Birth*

Reason for Removal*

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 Vehicle

Year, 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*

Collision Deductible*

When 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: agency@midcolumbiainsurance.com

Does this vehicle have any non-stock/special equipment?*

Yes
No

Describe all non-stock/special equipment*

Describe all non-stock/special equipment

Does this vehicle have any existing damage?*

Yes
No

Describe all existing damage*

Describe any existing damage

Vehicle 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)?*

Yes
No

Do you want Personal Injury Protection coverage added (if not already on policy)?*

Yes
No

Do you want Rental Car reimbursement coverage? (if available)*

Yes
No

Do you want Roadside Assistance Coverage (Towing)? (if available)*

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 Vehicle

Year, Make, & Model of Vehicle*

Reason for Removal*

Some companies may require a signed request to remove a vehicle. If required, we will email you the form for e-signature or your can write out the request and send it to us by email or attach it below where it says: "Send Documents"

Update Car Loan Info

Car 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 Fax

Finance Company Email

Upload Car Loan Info

Change Coverages on an Vehicle Currently on Policy

If 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.

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*

New Collision Deductible*

New Liability Limits*

New PIP Limits*

New UM Limits*

Roadside Service*

Rental Car Reimbursement*

Additional Info or Other Changes Requested

Send Documents

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.

Name

This field is for validation purposes and should be left unchanged.