Auto Policy Change Request

Summary of Requested Changes

Please note, policy changes take place at 12:01 a.m. on the date of change.

I am...

Comments or additional notes to staff:

NOTE: Only a named insured may request changes to a policy. If you have information to provide on behalf of a named insured, we will accept the information and then reach out to the insured to confirm the requested changes.

Client Name

First NameLast Name

Client Phone Number:

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

Your Name (name of person completing this form) if other than Client Name:

First NameLast Name

Client E-Mail Address:

example@example.com (if no e-mail address type mailhardcopy@iscinsurance.com)

What type of change are you requesting (select one option only):

What Type of Policy Change Do You Wish to Make

Other

Is this change for a SINGLE VEHICLE POLICY or a PROGRESSIVE "toy" (Cycle, Snowmobile, ATV, etc)?

Which vehicle(s):

What date do you want this change to occur (Note: changes occur at 12:01 a.m. - if you need coverage for a partial day, select the following day)

(Please note we will request the effective date noted above. All effective dates are subject to the insurance company's guidelines.)

Coverage Being Reduced at Client's Request*

Client Notification - Important Information Regarding Your Coverage Change

Comprehensive coverage includes damage caused by fire, theft, wind, hail, vandalism, etc. Once this change has been processed, there will be no liability or collision coverage on the vehicle. Therefore, it is extremely important that you call our office to restore coverage prior to anyone driving the vehicle.

·     Coverage will not be automatically restored at a future date. You must notify our office when you are ready to have coverage re-added.
·     “Storage coverage” is not offered by all companies. If not allowed by your company, we will instead drop coverage down as low as allowable.
·     If you have a loan, not all lenders allow comprehensive (storage coverage). It is your responsibility to make sure you are in compliance with your loan agreement.

You will be receiving an amendment directly from the insurance company in the next few days. Please review it carefully, and If you have any questions or concerns, please let our office know.

RESTORE Coverage Options:

Please restore vehicle/unit to the same coverages, deductibles, optional coverages, endorsements, and vehicle usage that were in effect immediately before coverage was reduced for storage. I understand that it is my responsibility to carefully review the amendment or endorsement from the insurance company when it arrives and to notify Insurance Service Center promptly if corrections or updates are needed.

As requested, we will be removing all coverage other than Comprehensive (Other Than Collision) from the vehicle(s) indicated above. Comprehensive coverage includes damage caused by fire, theft, wind, hail, vandalism, etc.

Once this change has been processed, there will be no liability coverage on the vehicle. Therefore, it is extremely important that you call our office to restore coverage prior to allowing anyone to drive the vehicle.

Coverage will not be automatically restored at a future date. You must notify our office when you are ready to have coverage added.

You will be receiving an amendment directly from the insurance company in the next few days. Please review it carefully, and If you have any questions or concerns, please let our office know.

As requested, your coverage will be reduced to the minimum amount allowed by the company. For example:

-Liability limits will be reduced to the State Minimum Limit,

-Medical payments will be removed or reduced if possible,

-Uninsured/Underinsured Motorist Coverage will be removed or reduced if possible.

-Collision coverage (if applicable) will be removed if possible, or the deductible will be raised. Please be sure to check with your lender to make sure this is acceptable.

Coverage will not be automatically restored at a future date. You must notify our office when you are ready to have coverage added. It is extremely important that you call our office to restore coverage prior to allowing anyone to drive the vehicle.

You will be receiving an amendment directly from the insurance company in the next few days. Please review it carefully, and If you have any questions or concerns, please let our office know.

As requested, we will be re-adding liability and physical damage coverage to the vehicle listed above. We will match the coverage to what you had before you put the vehicle in storage. Please feel free to review the optional coverages below and let us know if you are interested in adding any new coverage options.

Do you have an umbrella liability policy?

DELETE this vehicle from the policy:

Provide Year, Make, Model. Please Include last 5 digits of VIN if you have similar vehicles. Example: 2010 Ford Focus *87638

Reason for Removing Vehicle:

Other

Date to DELETE Vehicle: NOTE: changes are effective at 12:01 a.m. If you need coverage for any amount of time during a day, you should use the next day. Example, if you will be trading in a car at noon on 1-3-20, you should delete that vehicle as of 1-4-20.

Insurance company may require proof of sale to back date a transaction, and typically have limits on how far back a transaction can be backdated.

Date and Time of the Trade-In/Purchase?

Date
Time (Time is only needed for future transactions)

NOTE: ISC will process the change in accordance with the guidelines of your specific insurance company. It may result in one or two amendments depending on the insurance carrier and the timing of the transaction.

Date and Time of the Trade-In/Purchase? (Time is only needed for future transactions) NOTE: ISC will process the change in accordance with the guidelines of your specific insurance company. It may result in one or two amendments depending on the insurance carrier and the timing of the transaction.

Date

Hour MinutesAM/PM Option

Date to Add New Vehicle: NOTE: changes are effective at 12:01 a.m.

Date

ADD the following vehicle:

Vehicle:Year   Make   Model
Vehicle ID:VIN (Vehicle ID #)*
Estimated Annual Miles (average is 10,000)   Annual Miles
Primary Driver:   Driver
Name(s) on Title (or Lease Agreement)?   How Titled

*If additional processing instructions are needed, please add them to the comment section below.

Vehicle Usage:

Commute: Miles One Way to Work or School: Miles
Commute: Number of Days per Week: # of Days

Coverage Selection:

Which vehicle's coverage would you like to match? Please list the Year/Make/Model of the vehicle coverage you would like to match for the newly added vehicle?

If choosing to match coverage - we will match liability limits, medical payments, Uninsured/Underinsured Motorist Coverage, and if applicable comprehensive and collision coverage. Additionally we will match optional coverages such as towing, GAP, rental reimbursement, if applicable. etc. You will be given the option to add additional optional coverages.

Bodily Injury and Uninsured/Underinsured Limit

Other

Medical Payments

Other

Comprehensive (Other than Collision) - Provides coverage for fire, theft, vandalism, deer hits, hail, wind.

Collision - Provides coverage for collisions and damage from hit and run claims

Other

Type of Purchase

Other

Name and Address of Lender/Lessor:

This address is not the same as your payment address. It will typically be listed on your WISCONSIN TITLE & LICENSE PLATE APPLICATION (Section D). If no address is listed, we will proceed with the policy change without lender/lessor info so as not to delay coverage. Please provide this information at your earliest convenience. Office Use: AW mlp

GAP Coverage for Loan/Lease - helps pay off the difference between what you owe and what your vehicle is worth in the event of a total loss. Does not include rolled-in balances. Price typically ranges from $2 to $8 per month depending on vehicle value.

Drive for Hire (Uber, Lyft, snow plowing, delivering mail, etc.)

Limited coverage for rideshare and delivery services such as Uber, Lyft, Door Dash, etc. (Only available from certain companies. Need advanced approval)

Towing / Roadside Assistance

Reimbursement for towing and/or roadside assistance. Varies by company.

Glass Deductible Waiver ($0 Glass Ded)

Waives your comprehensive deductible when you need to have a windshield / window REPLACED due to a claim. Deductibles are typically automatically waived for a repair (such as a small chip).

Rental Reimbursement (Travel Expense)

Helps pay the daily cost of a rental car while your vehicle is being repaired due to a claim.

Rental Car Gap (Enhanced Coverage)

Helps cover gaps in coverage when you rent a car, such as on vacation. Gaps can include things like loss of use and/or diminished value. Coverage and availability varies by company.

Trust or LLC as Additional Insured

If your vehicle is owned by a Trust, LLC or other entity (not your personal name) special adjustments need to be made to the policy. Often there is no charge, but this is a very important step.

Original Manufacturer Parts

Available on newer vehicles only. This coverage allows for brand new parts directly from the manufacturer versus after-market or salvaged parts.

Company Vehicle

Provides expanded coverage for a vehicle owned by your employer. We highly recommend this coverage unless you are certain of the details/coverage provided by your employer.

Replacement Cost (or Increased Cost)

Allows for a replacement vehicle or increased coverage for a loss on a new vehicle. Not offered by all companies and coverage varies greatly by company.

Non-Owned Vehicle

Provides expanded coverage when you have regular access to drive a vehicle that you do not own. Instances could be roommates / significant others in the same household, using grandparents' vehicles often, etc.

Accident / Violation Forgiveness

When available, this endorsement eliminates accident or violation surcharge for a future incident. Can be beneficial with youthful drivers.

Customization Coverage

Provides coverage for conversion packages, medical lifts, chrome rims, truck tops, special paint jobs, etc.

Agreed Value Coverage

Primarily used on collector cars or high-valued vehicles. Agreed value provides a pre-determined amount that will be used as the value in the event of a loss. This must be approved in advance by underwriting.

Vehicle for Hire (Turo, HyreCar etc)

Coverage for renting out your vehicle such as Turo. (Only available through certain companies. Need advance approval).

Life Insurance to help with vehicle loan?

Diminished Value

Helps offset potential loss in resale value due to vehicle being damaged. NOT AVAILABLE WITH ALL COMPANIES.

List names of all household members age 15 and older, EVEN IF THEY DO NOT DRIVE.

Rows	Name	Driver?	Vehicle	Notes
1
2
3
4
5
6

Does anyone else (not listed above) regularly drive OR have ongoing permission to drive your vehicles?

Include anyone else who drives your vehicles frequentlyor has standing permission to use them.You do not need to list someone who only drove your car once or twice.

Do any drivers regularly drive or have access to drive a NON-OWNED vehice? Examples include: a company car, a neighbor's car, a significant others vehicle. Etc.

Do any drivers live outside your house? (Examples: child at college, adult child who moved out, separated/divorced spouse)

Details regarding driver living outside of the home:

Co-Titled Vehicles? Do you own or co-own any vehicles with anyone other than a legal spouse? (Examples: your child, unmarried significant other, separated/divorced spouse, a business entity)

Details regarding co-titled vehicles:

I understand I need to notify ISC right away if: 1) Anyone age 15+ moves into or out of my household - (including kids going to college) 2) A household member starts or stops driving 3) Someone outside my home begins driving my vehicle. 4) I buy, sell, co-sign, or co-title a vehicle. 5) Anyone begins using my vehicle(s) for hire or delivery services (such as Uber, Lyft, DoorDash, Grubhub, or similar.

Do you have any other questions or concerns, other changes you'd like to make or message for your agent?

Discount Review (Select any that might apply) - Provide additional details in comment section below. Not all discounts apply with every company.

*The summary above only reflects the coverage for the listed vehicle only. All coverages are subject to underwriting approval, availability, and driving record. This is just a very simple summary, all terms, provisions, and exclusions in your policy apply.

**Not all available optional coverages are listed. Not all optional coverages are available from all companies.

The cost of bodily injury claims has risen steadily over the past several years. We are happy to review your coverage and/or provide you with alternate quotes at any time.

It is extremely important that you let us know if your situation changes. This includes changes in the household, new drivers, drivers living outside your home, additional vehicles, any sort of business use (such as snow plowing, Uber, Lyft, Turo, USPS, Amazon, food delivery, etc).

Please review the information above carefully and contact our office immediately if any updates are needed, or if you have any questions or concerns. Once we have submitted the request to the insurance company, they will send you an amended declaration page. As always be sure to review that information for accuracy as well.

Thank you for choosing Insurance Service Center!

I understand that if my situation changes, I need to notify ISC. I understand driving for hire/renting vehicles, undisclosed drivers may result in a declination of coverage. I understand that if I have reduced coverage, it will not be automatically updated in the future. I need to notify ISC when future changes are wanted.

Signature of NAMED INSURED

ISC Staff: Name of Person You Spoke With:

ISC Staff: Your e-mail address:

example@example.com

Because signature is requested. YOU MUST TYPE mailhardcopy@iscinsurance.com in the box below. If this step is not completed a copy will not be sent to client for signature.

Type: mailhardcopy@iscinsurance.com

A copy of this form will be sent to:

-{clientEmail}

-{iscStaff53}

-file@iscinsurance.com for entering in AMS

-service@iscinsurance.com for processing

Office Use:

example@example.com

File Copy:

example@example.com

Auto Insurance Policy Change Request

Optional Coverage