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*
MM slash DD slash YYYY
Hidden
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*
MM slash DD slash YYYY
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*
Max. file size: 128 MB.
Remove a Driver
Name 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 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: [email protected]
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)?*
- 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 Vehicle
Year, 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 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
Max. file size: 128 MB.
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.
👉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*
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
Max. 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.
Comments
This field is for validation purposes and should be left unchanged.

Save and Continue Later

Auto Change Request

Changes to Make

Policy Holder Information

Contact Information

Add a Driver

Get the Discount

Remove a Driver

Add a Vehicle

Remove a Vehicle

Update Car Loan Info

Change Coverages on an Vehicle Currently on Policy