Request Changes to Your Policy
CHANGE OF VEHICLE
Policyholder's Name:
E-Mail Address:
Policy Number:
(if you know it)
Phone Number:
in case we need to discuss coverages with you
Change Effective Date:
Type of Change:
Adding a new vehicle
Changing vehicle
NEW VEHICLE INFORMATION
Vehicle Year:
Make:
Model:
Vehicle ID Number:
(also known as the VIN number)
Does the vehicle have an alarm system?
Yes
No If yes, type:
(Certificate required)
Does the vehicle have an airbag?
Yes
No
Is there a lienholder on this new vehicle?
Yes
No
Name of Dealer:
(if applicable)
Phone Number:
VEHICLE TO BE DELETED
Vehicle Year:
Make:
Model:
Vehicle ID Number:
(also known as the VIN number)
Have the plates been turned into the Registry of Motor Vehicles?
Yes
No
Comments: