Client Service Request

Name of Person Submitting this form

First NameLast Name

Name of Policy Holder

Email

example@example.com

Phone Number

Please enter a valid phone number.Format: (000) 000-0000.

What request do you need help with:

Is this vehicle replacing a current vehicle

What vehicle are you replacing:

Rows	Year	Make	Model
Old Vehicle

I would like to:

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.

New Vehicle Info:

Rows	Year	Make	Model	VIN
New vehicle

This vehicle has:

Who is the legal owner of this vehicle?

Who is the primary driver of this vehicle?

This vehicle will be driven for:

Other

Please describe the business use:

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?

Where will this vehicle be primarily kept?

This vehicle was

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.

What is that mailing address?

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

What coverages do you want for this vehicle?

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?

Did you already purchase this vehicle?

When did you purchase it?

When do you plan on purchasing this vehicle?

What vehicle are you removing?

This vehicle:

Other

Date sold or title signed to another business or person

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?

Upload proof of sale (bill of sale, copy of title that's been signed by both parties, etc.)

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.

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.

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:

If you are wanting to add either comprehensive or collision to a vehicle ( including taking something out of garage coverage to add collision back on), we have to have current pictures of the vehicle. Please upload, text, or email us 2 pictures of the vehicle. 1 showing the front and 1 side of the vehicle, the 2nd showing the back and the other side of the vehicle. We have to upload this with the change for it to be approved by the insurance company.

What date did you move or are you moving?

Date

What policies need to be updated with this address change?

New Address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Will you be using a different mailing address (like a PO Box)?

What is the mailing address?

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Do you have a homeowners policy with us?

Are you buying a new home?

What is happening with the old home (selling, keeping it and renting it out, etc.)?

Are you leaving a job with this move?

Did you have a 401k at that job?

New Driver Name:

First NameLast 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)

Other

Marital Status

Relation to the Policy Holder (Named Insured)

Is this new driver a full time student?

Does this new driver qualify for the Good Student discount (at least a B average)?

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.

Is this new driver willing to do driving tracking to receive extra discounts for showing safe driving habits?

Does this driver have any tickets, accidents, or filed claims in the last 5 years?

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.Format: (000) 000-0000.

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?

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.

Other

I'm requesting this change for:

Other

We have multiple insurance companies we work with. Can we run quotes with our other companies to try to retain your business?

What policies are you requesting be cancelled?

What is the reason you're requesting cancellation?

When do the new policies start?

Date

If this request is for a date before today, we cannot backdate without declarations pages for the new policies. Below are you options:

If you have the declarations already available, upload them here:

This will not cancel your policy. We will need to send you a signature request.

What is the date this incident happened?

Date

Is this claim for:

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?

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

CityState / Province

Postal / Zip Code

Phone Number for the Cert Holder

Please enter a valid phone number.Format: (000) 000-0000.

Email address for the Cert Holder

example@example.com

Do we need to send it to anyone's attention?

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).

This is for my:

Other

Is this replacing an existing loan (refinance situation)?

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

CityState / 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)?

Date

What can we help you with?