Account Manager Request Form Remove / Delete Vehicle Request Form
Client Name / Name of Person Requesting the Change
*
First Name
Last Name
Name of Account Manager Requesting Change
*
Please Select
Joy McFarlane
Shirley Monson
Kathy Busse
Gabby Ruder
Melissa Rodriguez
Name of Account Manager Requesting Change
Effective Date of Change
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Will You Be Adding or Replacing This Vehicle?
*
No
Yes - But Not Yet so Delete Only For Now
Yes Now - DO NOT USE THIS FORM! Use the ADD/REPLACE Vehicle Form
Do You No Longer Own the Vehicle or Just Want to Remove All Coverage?
*
No Longer Own = Sold / Donated / Disposed of the Vehicle
Keeping Vehicle but Removing All Coverage
If You are Keeping the Vehicle and Deleting All Coverages - Do you understand that the vehicle would not be legal to drive and your policy would provide no coverage if you drove it or allowed someone else to drive it and they were involved in an accident or claim.
*
Yes
No - IF NO then Do Not Delete Coverage Without getting their request in writing. You must Explain or Read to Client: If You Are Placing in "Storage" temporarily, we recommend keeping at least Comprehensive Coverage in force. You must add the vehicle back before it is driven again as liability and collision coverage would not apply while in storage.
VIN of Vehicle Being Deleted
*
Year / Make / Model of Vehicle Being Deleted
*
Does removing this vehicle leave only 1 vehicle on the policy?
*
Yes
No
Did this policy have stacked PIP?
*
Yes - The policy will lose stacked PIP, so you need to add additional PIP coverage
No, this policy did not have stacked PIP
Any additional information related to this change?
Ex: Change of use, driver changes, purchasing new vehicle later
Submit
Should be Empty: