Personal Change Form

1
Personal Information* This field is required.
Cell Phone Number (we will text you confirmation of your change request)
Please Select
Please Select
AL
AK
AZ
AR
CA
CO
CT
DE
FL
GA
HI
ID
IL
IN
IA
KS
KY
LA
ME
MD
MA
MI
MN
MS
MO
MT
NE
NV
NH
NJ
NM
NY
NC
ND
OH
OK
OR
PA
RI
SC
SD
TN
TX
UT
VT
VA
WA
WV
WI
WY
Please select your state
2
Effective Date of Change* This field is required.
Date
Month
Day
Year
3
What Do You Need To Change Today?
Auto
Home/Dwelling Fire
Motorcycle/ATV
Watercraft
RV/Travel Trailer/Horse Trailer
General
Billing
Claims
Cancellation
Document Request
4
Auto Change Type
Add Vehicle
Delete Vehicle
Replace Vehicle
Add Driver
Delete Driver
Change Coverage or Deductible
Change Lienholder
Vehicle Use/Mileage
5
Home Change Type
Mortgage Change
Dwelling Updates
Delete Scheduled Items
Remodel/Additions/New Building
Deductible Change
Coverage Change
Add Scheduled Item
Change Scheduled Items
6
Motorcycle/ATV Change Type
Add Vehicle
Delete Vehicle
Replace Vehicle
Add Driver
Delete Driver
Change Coverage or Deductible
Change Lienholder
7
Watercraft Change Type
Add Watercraft
Delete Watercraft
Replace Watercraft
Add Driver
Delete Driver
Change Coverage or Deductible
Change Lienholder
8
RV/Travel Trailer/Horse Trailer
Add RV/Trailer
Delete RV/Trailer
Replace RV/Trailer
Add Driver
Delete Driver
Change Coverage or Deductible
Change Lienholder
9
General
Physical Address
Billing Address
Phone Number
Email Address
Marital Status
Not Listed
10
Document Request
ID Card
Declarations Page
Evidence of Insurance
Claims History
11
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Please Select
Please Select
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Country
12
Email
example@example.com
13
Home Phone
Area Code
Phone Number
14
Cell Phone
Area Code
Phone Number
15
Which Vehicle Are We Deleting?
16
What Vehicle Are We Adding?
17
Year, Make, Model of Vehicle* This field is required.
18
Type of RV/Trailer* This field is required.
RV
Travel Trailer
Horse Trailer (w/ living quarters)
Other
19
Slide-Outs?
1
2
3
4
20
Length* This field is required.
21
Current Value* This field is required.
22
Cost New* This field is required.
23
Hull Material
Fiberglass
Aluminum
Inflatable
Roplene
Carbon Fiber
Rotomolded
24
Propulsion Type
Outboard
Inboard/Outboard
Inboard
Jet
Sailboat Powered (inboard)
Sailboard Non-Powered (outboard)
25
Motor Information
26
Purchase Year
27
Original Owner
Yes
No
28
Storage Info
Please Select
Please Select
Parking Lot
Lift
In-Water
Yard
Driveway
Garage
Storage Type
29
Trailer Value
30
What Type Is It?* This field is required.
ATV
UTV
Mini-Truck
Golf Cart
Motorcycle
Trike-Motorcycle
Other
31
Engine CC's (or HP)* This field is required.
32
If Truck, Type of Bed
Regular
Flat Bed
None
33
Bed Value if Aftermarket
34
Name on Title
35
Annual Mileage* This field is required.
36
Vehicle Usage
Pleasure Only
To and From Work
37
Vehicle Used For Pickup or Delivery In A Business
Yes
No
38
Ride-sharing Use? (Uber, Lyft)
Yes
No
39
Vehicle Used In Any Other Type Business?
Yes
No
40
Explain Business Use
41
Which Comprehensive Deductible Would You Like?This is your out of pocket for things like fire, theft, hail, vandalism, animal collision and glass damage.
$100
$250
$500
$1,000
Decline (Liability Only)
42
Which Collision Deductible Would You Like?This is your out of pocket for things other than comprehensive damage to your vehicle.
$100
$250
$500
$1,000
Decline (Liability Only)
43
Would You Like Roadside Coverage?
YesNo, decline coverage
44
Would You Like Rental Reimbursement?
$30 per day
$40 per day
$50 per day
No, decline coverage
45
Interested In The Following Options?* This field is required.
Loan/Lease Coverage (if available)
New Car Replacement (if available)
OEM Parts (if available)
None
46
Interested In The Following Motorcycle/ATV Optional Coverages?* This field is required.
Replacement/Total Loss Coverage (available on newer vehicles)
Trip Interruption
Carried Contents
Transport Trailer Physical Damage
Enhanced Injury Protection
Rental Vehicle
None
47
Interested In The Following RV/Travel Trailer Optional Coverages* This field is required.
Total Loss Replacement
Pest Damage Protection
Roof Protection Plus
Emergency Vacation Expense
Disappearing Deductibles
Full Timers Package
Roadside Assistance
None
48
Interested In The Following Watercraft Optional Coverages?
Total Loss Replacement
Disappearing Deductible
On-Water Towing/jump/fuel
Propulsion Plus (Progressive, motor mechanical breakdown)
Trailer Trip Interruption Coverage
Fishing Equipment
Personal Effects
Roadside
Fuel Spill Liability (Progressive)
49
Do You Have Accessories or After Market Parts That Exceed $3,000 In Value?Auto: Stereo, Camper Shell, Bed Cover, Wheels, Lift, Suspension, Flat Bed, Tool Box, Lights, Etc. Motorcycle: Chrome, Saddle Bags, Windshield, Stereo, Exhaust, Etc.
50
Stored In A Garage?
Yes
No
51
Added Driver Info* This field is required.
First Name
Last Name
Date of Birth
Drivers License Number
52
Deleted Driver Info
53
Operator Experience* This field is required.
Number of Years
54
Tickets or Accidents Past 5 Years?
List description, date and claim amount
55
Is This A Student? If so...
B or 3.0 Average or Higher in School
Driver Training
Away At College With No Car
Not A Student
56
Describe Coverage/Deductible Change Requested* This field is required.
57
Lienholder* This field is required.
Yes
No
58
Leased or Financed?
Leased
Financed
59
Lienholder Change Type* This field is required.
Add
Delete
Replace
60
Lienholder Vehicle Description* This field is required.
Year, Make, Model
61
Deleted Lienholder Name* This field is required.
62
Lienholder Name* This field is required.
63
Lienholder Address* This field is required.
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Please Select
Please Select
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Country
64
Mortgage Change* This field is required.
Add
Delete
Change
Add 2nd
65
Deleted Mortgage Name* This field is required.
66
New Mortgage Name* This field is required.
67
New Mortgage Address* This field is required.
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Please Select
Please Select
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Country
68
Describe Deleted Scheduled Items* This field is required.
69
Describe New Scheduled Item In Detail (year, make, model, type, material, size, clarity, color, APPRAISED VALUE (or purchase price), etc.)* This field is required.
70
Describe Dwelling Updates (type, material, layers, etc.)* This field is required.
71
Describe Remodel/Additions/New Building (type, materials, square feet, heat, etc.)* This field is required.
72
Describe Scheduled Item Change* This field is required.
73
Explain Marital Status Change* This field is required.
74
Additional Comments
75
Which Vehicle(s)
Huge
Large
Normal
Small
Ok
Ok
76
Reason for Cancellation
77
First Name
78
Last Name
79
Email
example@example.com
80
Phone
81
Send confirmation (and documents) by?* This field is required.
Text
Email
Fax
Mail
82
Signature Required* This field is required.I understand that the request I'm making potentially removes or reduces coverage and I authorize Heritage to make this change.
Clear
83
Terms and Conditions* This field is required.
Should be Empty: