Client Service Request
Name of Person Submitting this form
*
First Name
Last Name
Name of Policy Holder
*
Email
*
example@example.com
Phone Number
*
Please enter a valid phone number.
What request do you need help with:
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I need to add a vehicle (if you traded in 1 vehicle for this new vehicle, choose only this option)
I need to remove a vehicle
I need to add a driver
I need a quote for a vehicle (if you've already purchased this vehicle, choose only the "I need to add a vehicle" above)
I need to change my coverage/deductibles or want a quote for changing coverage/deductibles
I need to change my address
I need to change my billing
I need a certifcate of insurance (business policies only)
I need to report a claim or have a question about being covered for a potential claim
I want to cancel my policy or policies
I need to update my loan company
Other
Is this vehicle replacing a current vehicle
No
Yes, I traded in a vehicle
Yes, I sold a vehicle
Yes, a vehicle was totalled out from an accident
Yes, I am currently trying to sell a vehicle
What vehicle are you replacing:
*
Rows
Year
Make
Model
Old Vehicle
I would like to:
Leave this vehicle covered until it's sold
Remove this vehicle now
Discuss this further with my agent
I understand that by choosing this option, I am leaving myself uninsured for anything that happens with this vehicle, including what may happen during test drives. I could also get fined by the State for not having insurance on this vehicle. I agree that this is against the advice of my agency and hold them harmless for any issues that come from this request.
I agree
I don't agree, leave this on my policy until I sell it
New Vehicle Info:
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Rows
Year
Make
Model
VIN
New vehicle
This vehicle has:
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Blind Spot Sensors
Automatic Braking
None of the above
Who is the legal owner of this vehicle?
*
Who is the primary driver of this vehicle?
*
This vehicle will be driven for:
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Pleasure Use
Commuting to/from work/school
Business Use
Other
Please describe the business use:
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Approximate # of miles 1 way to work
*
How many days per week do you commute to work?
*
How many miles per year to you expect to put on this vehicle?
*
Will this vehicle be primarily kept at your home address?
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Yes
No
Where will this vehicle be primarily kept?
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This vehicle was
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Purchased or inherited with no loan
Purchased with a loan
Leased
When did you purchase or lease this vehicle?
*
The name of the loan or lease company is (if you're not sure, just type "will follow up":
*
Do you have the mailing address for the loan or lease company? Make sure this is the address for insurance paperwork and not the address you send payments to.
No
Yes
What is that mailing address?
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
What coverages do you want for this vehicle?
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Same as vehicle being replaced
Same as another vehicle on the policy
I want this vehicle to have different coverage
I don't want coverage for physical damage to this vehicle, only liability
Other
Which vehicle do you want us to match coverages from?
*
What coverages do you want for this vehicle? Enter deductible amounts. If you don't want the coverage, enter "none"
Rows
Collision
Comprehensive
New Vehicle:
If offered, do you want any of these optional coverages:
*
Will this vehicle be used for Uber, Lyft, DoorDash, Uber Eats, or any other rideshare or delivery service?
*
Yes
No
Did you already purchase this vehicle?
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Yes
No
When did you purchase it?
*
When do you plan on purchasing this vehicle?
*
What vehicle are you removing?
*
This vehicle:
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Was sold or title already signed over to another person or business
Is listed for sale, but not sold yet
Is no longer running, but I still own it
Was totalled out in an accident and title has been signed over to the salvage yard or the insurance company
Other
Date sold or title signed to another business or person
*
-
Month
-
Day
Year
Date
If the sale date was before today, we need proof of sale to backdate. Otherwise, we can use today's date. How would you like to proceed?
*
Not Applicable to Me
Use today's date
I'll email you proof of sale to service@edenins.com
I have proof I can upload now
Upload proof of sale (bill of sale, copy of title that's been signed by both parties, etc.)
Browse Files
Drag and drop files here
Choose a file
Cancel
of
Since you are actively trying to sell the vehicle, we recommend you don't remove the vehicle. Should an accident occur between now and when the title is signed over to someone new (even if during a test drive), you will not be covered and you are the one still responsible for this vehicle, not the driver. This could result in losing your license and paying for a claim out of pocket. You would also have to pay out of pocket if the vehicle rolls and hits someone or something, it's stolen, it's vandalized, etc.
*
I'll keep coverage for now and let you know when it sells
The vehicle isn't drivable, and I am OK with the above risks. Please remove it and I'm agreeing to hold you harmless for anything that comes from this vehicle moving forward.
Please call me to discuss this further
When removing a vehicle that is no longer running, you are making yourself fully responsible for everything that happens to (or with) that vehicle. If it rolls away and causes damage or injuries, you will pay those out of pocket as you will have no coverage. If it's stolen, vandalized, caught in a house/apartment fire, etc, you are not covered at all and no other policy will cover this vehicle. You also cannot drive it again until you've let us know you wanted it added back on AND we have processed the change. So if you get it running on a weekend and want to take it out, you won't be able to until we get your request and process it on a regular business day. An option to at least add coverage back for theft, vandalism, fire, falling/flying objects, and wind/hail damage would be to put garage coverage on the vehicle. It can't be driven, but at least will be covered if damage happens to the vehicle from those situations.
*
I understand and would like to put garage coverage on this vehicle
I understand and would still like to remove it.
Please call me to discuss this further
Please describe in detail what change(s) you want to make, including the specific policy and/or coverage you want to make changes to. If you just want a quote for now, please make sure to note that:
*
What date did you move or are you moving?
*
-
Month
-
Day
Year
Date
What policies need to be updated with this address change?
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Auto
Home/Condo/Renters
Life
Health
Business Policies
Other
New Address:
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Will you be using a different mailing address (like a PO Box)?
*
Yes
No
What is the mailing address?
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Do you have a homeowners policy with us?
*
Yes
No
Are you buying a new home?
*
Yes
No, I'll be renting
No, I'll be living with family
No, I'll be living with someone not related to me
Other
What is happening with the old home (selling, keeping it and renting it out, etc.)?
*
Are you leaving a job with this move?
*
Yes
No
Did you have a 401k at that job?
*
Yes
No
New Driver Name:
*
First Name
Last Name
New Driver Date of Birth:
*
New Driver License Number:
*
Date their license was 1st issued (listed on a new license, if unknown estimate as close as possible)
*
Gender (as listed on their license)
*
Male
Female
Other
Marital Status
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Single
Married
Separated
Widowed
Other
Relation to the Policy Holder (Named Insured)
*
Spouse
Child
Significant Other
Parent/Grandparent
Relative
Roommate
Not Related
Other
Is this new driver a full time student?
*
Yes
No
Does this new driver qualify for the Good Student discount (at least a B average)?
*
Yes
No
Do you have proof of their grades? If so, please upload here. Make sure it is the full form showing not only grades and what semester or school year, but also the student name.
Browse Files
Drag and drop files here
Choose a file
Cancel
of
Is this new driver willing to do driving tracking to receive extra discounts for showing safe driving habits?
*
Yes
No
Does this driver have any tickets, accidents, or filed claims in the last 5 years?
*
Yes
No
Please provide information on those incidents
*
Rows
Date (at least an estimated month and year if you don't have the exact date)
Description (at fault accident, not at fault, hit an animal, speeding 15mph over, etc.)
For claims, about how much was paid out?
Incident 1
Incident 2
Incident 3
Incident 4
What is their phone number?
Please enter a valid phone number.
What is their email address?
example@example.com
If available, is this new driver willing to do new driver online safety courses for extra discounts?
*
Yes
No
Which vehicle will this driver be driving?
What did you want your new billing method to be? The top is usually the best rate, and the rates will keep getting higher as you move down the list.
*
Paid in Full with Automatic from Checking or Credit Card
Paid in Full, not automatic
Monthly Automatic from Checking or Savings
Monthly Automatic from a card
Monthly Non Automatic
Other
I'm requesting this change for:
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All my policies
Just my auto
Just my home/condo/renters
Other
We have multiple insurance companies we work with. Can we run quotes with our other companies to try to retain your business?
*
Yes
No
What policies are you requesting be cancelled?
*
What is the reason you're requesting cancellation?
*
When do the new policies start?
*
-
Month
-
Day
Year
Date
If this request is for a date before today, we cannot backdate without declarations pages for the new policies. Below are you options:
Use today's date
I'll provide my declarations
Not applicable to me
If you have the declarations already available, upload them here:
Browse Files
Drag and drop files here
Choose a file
Cancel
of
This will not cancel your policy. We will need to send you a signature request.
*
I understand
What is the date this incident happened?
*
-
Month
-
Day
Year
Date
Is this claim for:
*
Auto
Home
Business
Other
Who was driving? If you vehicle was parked, put "parked"
*
What vehicle was involved?
*
Please describe what happened:
*
Do you have an estimate for the repairs?
*
Yes
No
What is the amount of the estimate?
*
Name of person or business needing the Certificate (Cert Holder Name):
*
Address for the Cert Holder
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number for the Cert Holder
*
Please enter a valid phone number.
Email address for the Cert Holder
*
example@example.com
Do we need to send it to anyone's attention?
*
Yes
No
Who's attention does it go to?
*
Any special instruction for this cert? (additional insured, waiver of sub, job site, location reference, etc.)
*
This request does not change your policy. We have to process the change before you're covered. If you want to verify if your specific situation would qualify for automatic coverage, call the office and discuss with a licensed member of our team (if you haven't already done this).
*
I understand
This is for my:
*
Auto
Home/Condo
Motorcycle/ATV
Other
Is this replacing an existing loan (refinance situation)?
*
No
Yes
What vehicle/motorcycle/ATV/etc. is this associated with?
*
Name of new loan company
*
Address for the loan company (where they want to receive proof of insurance)
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
What is the loan number? (leave blank if unknown or not needed)
What is the effective date of this change (loan closing date)?
-
Month
-
Day
Year
Date
What can we help you with?
*
Back
Next
Is there any additional information that will help us process your request?
Submit
Should be Empty: