Auto Policy Change Request
Client Name
*
First Name
Last Name
Email
*
Phone
*
Format: (000) 000-0000.
Policy Number
Skip if unknown
Do you need to update your address?
*
No
Yes, I've moved or have a new mailing address
Updated Address
*
Address
Address Line 2
City
State / Province
Postal / Zip Code
What do we need to get changed for you?
Mark ALL that apply. Multiple items can be checked.
Mark all the changes needed:
*
Add a vehicle
Remove a vehicle
Add a driver
Remove a driver
Update a Lienholder / LossPayee
Something else
Add a Vehicle
Adding a Vehicle
Effective date: When did you purchase or obtain this Vehicle?
*
-
Month
-
Day
Year
Date
Year
*
Make & Model
*
Vehicle VIN:
*
Manually enter
I can upload a photo or document with the VIN
VIN
*
Upload a photo or document with the VIN
*
Browse Files
Drag and drop files here
Choose a file
Cancel
of
Is this vehicle used for Ride share? (Uber, Lyft, Amazon Flex, etc)
*
No
Yes
Vehicle Coverage:
*
Liability Only Coverage
Full Comp & Collision Coverage
What coverage deductible do you want for this vehicle?
*
Same as my vehicles
$500
$1000
Have my agent recommend
Who own's the vehicle?
*
I own the vehicle
I lease the vehicle
Owned by someone else
Other
Does a lien holder need to be added for this vehicle?
*
Yes
No
Yes, but I don't have the info right now
Lienholder / Loss Payee
*
Lienholder Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Does the vehicle have any existing damage? (hail, dents, etc)
*
No
Yes
Give a brief description of the current damage.
*
Is there any added equipment you want covered? (Like bed-covers, camper-shells, hay-loaders, custom rims)
*
No
Yes
Give a brief description of the equipment you would like to cover?
*
What dollar amount do you want the equipment covered for?
*
Need to add another vehicle?
*
No
Yes
Effective Date: When did you purchase or obtain this Vehicle?
*
-
Month
-
Day
Year
Date
Year
*
Make & Model
*
Vehicle VIN:
*
Manually Enter
I can upload a photo or document with the VIN
VIN
*
Upload photo or document
*
Browse Files
Drag and drop files here
Choose a file
Cancel
of
Is this vehicle used for Ride share? (Uber, Lyft, Amazon Flex, etc)
*
No
Yes
Vehicle Coverage:
*
Liability Only Coverage
Full Comp & Collision Coverage
What coverage deductible do you want for this vehicle?
*
Same as my other vehicles
$500
$1000
Have my agent recommend
Who own's the vehicle?
*
I own this vehicle
I lease this insured
Owned by someone else
Other
Does a lien holder need to be added for this vehicle?
*
Yes
No
Yes, but I don't have the info right now
Lienholder / Loss Payee
*
Lienholder Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Does the vehicle have any existing damage? (hail, dents, etc)
*
No
Yes
Give a brief description of the current damage.
*
Is there any added equipment you want covered? (Like bed-covers, camper-shells, hay-loaders, custom rims)
*
No
Yes
Give a brief description of the equipment you would like to cover?
*
What dollar amount do you want the equipment covered for?
*
Remove a vehicle
Removing a Vehicle
Effective date to Remove this Vehicle
*
-
Month
-
Day
Year
Date
Why is the vehicle being removed?
*
Sold / Traded
Broken Down / Not Running
Still Owned - Insured on another policy
Other
Year
*
Make & Model
*
VIN or Plate
*
Notice: All coverage for this vehicle will end.
*
I verify that I no longer want any coverage for the vehicle
Remove another vehicle?
*
No
Yes
Effective date for Removing this Vehicle
*
-
Month
-
Day
Year
Date
Why is the vehicle being removed?
*
Sold / Traded
Broken Down / Not Running
Still Owned - Insured on another policy
Other
Year
*
Make & Model
*
VIN or Plate
*
Notice: All coverage for this vehicle will end.
*
I verify that I they no longer want any coverage for the vehicle
Remove another vehicle?
No
Yes
Effective date for Removing this Vehicle
*
-
Month
-
Day
Year
Date
Why is the vehicle being removed?
*
Sold / Traded
Broken Down / Not Running
Still Owned - Insured on another policy
Other
Year
*
Make & Model
*
VIN or Plate
*
Notice: All coverage for this vehicle will end.
*
I verify that I no longer want any coverage for the vehicle
Add a Driver
Adding a Driver
Name
*
First Name
Middle Name
Last Name
Suffix
DL Number
*
Date of Birth
*
-
Month
-
Day
Year
Date
How is the Driver related?
*
Child/Step Child
Spouse/Partner
Parent
Friend/Other
Does this Driver live in your household?
*
Yes
No
Employment / Occupation for this Driver?
*
Drive to Work &/or School
Homemaker
Full-Time Farmer/Rancher
Unemployed / Disabled
Other
Any Tickets, Accidents, or Claims in the last 3 years?
*
No
Yes
I'm not sure
Details for ticket, accident, or claim:
*
Discounts:
Full-time Student with 3.0 or better GPA
Drivers Ed (only applies to ages 16 - 19)
Defensive Driver Course Completed
Drives a Company Provided vehicle (to & from home)
100% Remote Worker
List the Company that Provides the Vehicle
*
Example: Shawnee Police Car or OHP
Documentation is required for discount: (Transcript or Completion Cert)
*
I have the document & can upload it now
I will submit documentation later
Upload the Discount document: Transcript or Completion Certificate
*
Browse Files
Drag and drop files here
Choose a file
Cancel
of
Remove a Driver
Removing a Driver
Name of Drive to Remove
*
First Name
Last Name
Date of Birth
*
-
Month
-
Day
Year
Date
Underwriting
*
This driver no longer lives in my household and is not a regular driver of any of my vehicles
This driver still lives in my household, but has obtained their own coverage
Upload Proof of Coverage: (AFR, Progressive, Etc) will not remove the driver until we submit proof of coverage.
*
Browse Files
Drag and drop files here
Choose a file
We can not process this change until your submit proof of coverage.
Cancel
of
Update a Lien holder / Loss Payee
Updating a Lien Holder / Loss Payee
Which vehicle lien needs to be updated?
Vehicle Year
*
Make & Model
*
Last 4 of VIN or PLATE#
*
Add or Remove a Lien from this vehicle?
*
Add a Lien
Remove a Lien
Did you receive a notice from the Lien holder?
*
Yes, I can upload that notice
No, I'll manually enter the Lien holder Name & Address
Lien holder Name
*
Lien holder Address
*
Address
Address Line 2
City
State / Province
Postal / Zip Code
Upload notice from the lien holder
*
Browse Files
Drag and drop files here
Choose a file
Cancel
of
Name of Lien holder to Remove
*
Do you need to Add or Remove another Lien holder?
*
No
Yes
Vehicle Year
*
Make & Model
*
Last 4 of VIN or PLATE#
*
Add or Remove a Lien from this vehicle?
*
Add a Lien
Remove a Lien
Did you receive a notice from the Lien holder?
*
Yes, I can upload that notice
No, I'll manually enter the Lien holder Name & Address
Lien holder Name
*
Lien holder Address
*
Address
Address Line 2
City
State / Province
Postal / Zip Code
Upload here:
*
Browse Files
Drag and drop files here
Choose a file
Cancel
of
Name of Lien holder to Remove
*
Other Changes
Other Auto Policy Changes:
How can we help?
Submit Request
Please indicate if any lienholder information related to the home, vehicles, or equipment could not be provided at this time.
*
Yes, one or more lienholder could not be provided
No, all lienholder information was provided
Not Applicable, this question does not apply to my situation
Are all licensed drivers in your household listed on your policy?
*
Yes, all licensed members of my household are listed on my policy
No
Submit
Should be Empty: