LCA Driver Change (Adding) Request Form

Driver Change (Adding) Request Form

California Low Cost Auto Insurance Program
Producer Name: Pacific Preferred Insurance

California License No. 0H55899

2775 N Ventura Road, Suite 110, Oxnard, CA 93036

800-913-1844

lowcostauto@pacificinsuresme.com
YesNo
NOTE: The California Low Cost Auto Insurance Program requires that you are financially responsible for the driver and proof may be required if you proceed.

Your Name*

First NameLast Name
Your Date of Birth*

MonthDayYear
Date
Email*
example@example.com
Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.
If the email or phone number entered above differs from what we have on file, please note it below to prevent delays in processing.
Mailing Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
YesNo
Physical Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
YesNo
Previous Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Integon National (Prefix IMPLC)21st Century (Prefix CAR)CAARP/AIO (Prefix AAP)Unknown (Not Assigned or Starts with 2)
Policy Number*
Requested Effective Date*

MonthDayYear
Date must be in the future - there is no backdating allowed. Soonest Date Accepted is Date Following Submission.
Name of Driver Adding to Policy:*

First NameLast Name
Date of Birth*

MonthDayYear
Date
SingleMarriedDivorcedWidowedOther
ChildSpouseSiblingOther
Notice: When adding a driver who is at least 19 years of age to your policy, they must also be added to any other active policy you have through the California Low Cost Auto Insurance Program. Failure to add them may result in a lack of coverage or potential claim denial.
YesNo
Policy Number of Other Policy (driver may be added to this policy if active): *
Agree
Important Documentation Requirements

When adding a driver to your policy, please ensure you provide the following documents for review:

1. Driver’s License
- A clear, legible copy of the driver's license must be uploaded for the individual you are adding to the policy.
2. Proof of Financial Dependence (if applicable):

If the individual is not currently listed on your policy as a household member (i.e., they were not included under the non-driver section of the original application), you must upload one of the following to demonstrate financial dependency:
- A copy of your tax return showing the individual listed as a dependent.
- A benefit verification letter with the individual included.
Note: All submitted documents will be reviewed for acceptability to ensure compliance with policy guidelines.
File Upload*

Upload Documents Here
Cancelof
Terms of Use for Submission of Change Form

By submitting this change form and signing below, you confirm that the information provided is accurate to the best of your knowledge. Our agency is not liable for forms not processed by us or the insurance company, and it is your responsibility to follow up if confirmation is not received within 30 days.

We are not responsible for submission errors, including technical issues that may prevent delivery. You must verify successful submission. Submission of this form does not confirm policy status, and if the insurance company deems your policy inactive at the time of submission, the request will be void. The effective date of any changes will be the day following successful submission to the insurance company, or a future date as indicated on the form. Backdating is not permitted.

If the information provided does not match our records or if we cannot locate your account, this request may be disregarded. Please ensure all information is accurate.

Hold Harmless and Release of Liability

By submitting this form, you release and hold harmless our agency, its officers, agents, employees, and affiliates from any liability, claims, or actions arising from the use or submission of this change form, including issues related to processing, delivery, or acceptance by the insurance company. You acknowledge responsibility for accurate information and for following up if confirmation is not received within the specified time frame.

You understand that the California Low Cost Auto Insurance Program offers liability-only coverage and does not include physical damage or theft coverage (Collision or Comprehensive). If you have a lienholder, additional coverage may be required, and failure to secure it could lead to repossession or forced insurance by the lienholder. By submitting this form, you certify responsibility for obtaining any additional coverage as needed.
INSURED CERTIFICATION SECTION

I, the named insured of the above policy, under penalty of perjury, hereby certify to the best of my knowledge that:

I continue to meet the eligibility requirements for the California Low Cost Automobile Insurance Program.

ANY PERSON WHO KNOWINGLY MAKES AN APPLICATION FOR MOTOR VEHICLE INSURANCE COVERAGE CONTAINING ANY STATEMENT THAT THE APPLICANT RESIDES OR IS DOMICILED IN THIS STATE AND IN THE COUNTY SHOWN ON THE APPLICATION WHEN, IN FACT, THE APPLICANT RESIDES OR IS DOMICILED IN ANOTHER STATE OR IN ANOTHER COUNTY OF THIS STATE, IS SUBJECT TO CRIMINAL AND CIVIL PENAL TIES.

FOR YOUR PROTECTION CALIFORNIA LAW REQUIRES THE FOLLOWING TO APPEAR ON THIS FORM.

ANY PERSON WHO KNOWINGLY PRESENTS FALSE OR FRAUDULENT INFORMATION TO OBTAIN OR AMEND INSURANCE COVERAGE OR TO MAKE A CLAIM FOR THE PAYMENT OF A LOSS IS GUILTY OF A CRIME AND MAY BE SUBJECT TO FINES AND CONFINEMENT IN STATE PRISON.
Signature*

Powered by Jotform SignClear
Electronic Signature Name:

First NameLast Name
Disclosure and Certification

Before this form is submitted to a carrier, it will be reviewed by a certified representative at Pacific Preferred Insurance Brokers LLC. The undersigned certifies and acknowledges that upon review by the agency representative, who is authorized to act on behalf of the company, the form will be submitted to the appropriate assigned carrier for the insured as indicated on the form. If the carrier is receiving this form, the undersigned further certifies that the representative has been authorized to act on behalf of the agency.

Kenneth Goodwin

President, Managing Partner

Pacific Preferred Insurance Brokers LLC

CA Lic 0H55844
Should be Empty: