Change Vehicle Coverage

Use this form to change vehicle coverage on your existing policy. When changes are complete, review and check mark the Understanding of Change (last statement) then click the “Send Request” button at the bottom of the form.






Policy Name, Number and Contact
*Full Name:
*Policy Number:
Day Phone: (example: 509-555-1212)
–  ext.
*Email: (We respect the use of your email address)
Policy Level Coverage (will affect all vehicles)
Uninsured Motorist:
Definition
Personal Injury Protection:
Definition
Change Coverage on a Specific Vehicle
Make:
Model:
*Vehicle Identification Number (VIN):
Other than Collision Deductible:
Definition
Collision Deductible:
Definition
Any damage to vehicle?
Yes**    

No
Any special equipment?
Yes**    

No
Vehicle modified or salvaged?
Yes**    

No

Additional Information

When your change request is received by Mid-Columbia Insurance, a change form will be emailed back to you showing the changes we have made.  If the changes are correct, follow the instructions for doing an e-signature.  If you do not receive our change form by the next business day, please call us.

*

I understand that no changes will go into effect until I sign the change request that the agency will email me.

* Required Fields
** If answer is Yes please describe in Additional Information field


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