Account Manager Request Form Add / Replace Vehicle Request Form
Client Name / Name of Person Requesting the Change
*
First Name
Last Name
Name of Requesting Change
Name of Account Manager Submitting Form
*
Please Select
Shirley Monson
Joy McFarlane
Kathy Busse
Gabby Ruder
Melissa Rodriguez
Effective Date of Change
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Will This Vehicle Replace Any Vehicle Currently On The Policy?
*
Yes
No
What Vehicle Is Being Removed (replaced)
Effective Date to Delete
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
VIN
*
Year
*
e.g. 2021
Make
*
e.g. Toyota
Model
*
e.g. Sequoia Sport
How is Vehicle Titled
*
How Is The Vehicle Owned
*
Owned - No Loan
Owned - With A Lienholder (Loan)
Leased - With A Lessor (Leased)
Loan/Lease Gap Coverage Needed
Exclude - No Gap Exists (Down payment or value of trade-in high enough so no gap)
Exclude - Bought Gap from Dealer
Include - Wants/Needs Gap Coverage
Lienholder/Lessor Info
Vehicle Use
*
Pleasure (drive 3 or less miles to work/school)
Short Commute (drive 4 to 15 miles to work/school)
Long Commute (drive 16+ miles to work/school)
Business Use (drive personal vehicle to/from work appointments, meetings, or jobs
Will this vehicle be used for any Transportation Network Services such as Uber, Lyft, Shipt, Amazon, Door Dash,
*
No
Yes
Will this vehicle be used for any Peer-To-Peer Vehicle sharing platforms such as Turo or ZipCar?
*
No
Yes
Assigned Driver
*
Garaging Address
*
Garaging Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Annual Mileage (Actual or Estimated) *some carriers rate on this and require verification for low mileage credits)
*
e.g. 9,000
Any safety Features
*
Blind Spot Warning
Automatic Emergency Braking
Rear Backing Camera
Lane Departure Warning
Forward Collision Warning
None
Interested in Telematics For Additional Discounts?
*
Yes
No
Personal Injury Protection (PIP)
*
Stacked - Has 2 or more vehicles Insured
Additional/Increased PIP Medical & Work Loss
Declining Stacked and Additional PIP
Any Existing Vehicle Damage
*
Comprehensive Deductible
*
$250
$1,000
$500
$2,500
Excluded - Comprehensive
Collision Deductible
*
$250
$1,000
$500
$2,500
Excluded - Collision
Glass Deductible
*
$0 Glass Deductible
Same As Comprehensive deductible
Glass coverage is not available when comprehensive coverage is excluded
*
I understand
Towing or AAA
*
Include Towing
Include Towing & Quote AAA Membership
Exclude Towing but still quote Quote AAA Membership
Exclude Towing
Rental Reimbursement ***Rental Reimbursement is generally not available when Comprehensive and Collision coverage are excluded
*
$35/day - $1,050 max
All Reasonable Expenses
$40/day - $1,200 max
$50/day - $1,500 max
$75/day - $2,250 max
$100/day - $3,000 max
Exclude Rental Reimbursement
All Reasonable Expenses
Highest Available Carrier Limit
New Car Replacement (if eligible)
*
Yes
No
Accident Forgiveness (if eligible)
*
Yes
No
Diminution of Value - Perceived Reduction in Value After a Loss (if eligible)
*
Yes
No
Submit
Should be Empty: