Butler & Associates Insurance Agency Auto Policy Change: Information Needed
Please provide the following information for your new vehicle. Be as complete as possible for best service.
Name
*
First Name
Last Name
Email
*
example@example.com
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Year/Make/Model
*
VIN
*
17 Characters
Please be advised: if you are submitting a request to add or substitute a vehicle that was purchased 30 days or more in the past, you will receive coverage on the day the request is made.
Date of Purchase
*
-
Month
-
Day
Year
Date
Date Coverage Requested for New Vehicle
*
-
Month
-
Day
Year
Owner
*
Name of registered owner
Loan Or Lease
*
Yes
No
Provide Bank / Lender Name & Address
*
If there is a loan or lease include the name of the lender or leasing company and address
New Vehicle - Salvaged or Branded Title
*
Yes
No
How will you be using the vehicle
*
Commute to Work or School
Business Use
Pleasure Use
Commute Miles 1 Way
Annual Miles
*
If used in Business Please Describe How It Will Be Used
Will the vehicle be used in the following manner
*
Ride Sharing (Uber / Lyft)
Food Deliver (Door Dash)
Snow Plowing
None of the Above
Please Select Coverage for New Vehicle - SELECT ALL THAT APPLY
*
Liability
Physical Damage - Comprehensive & Collision
Full Glass Coverage
Towing / Roadside Assistance
Rental Reimbursement
New Car Replacement
Same Coverage as vehicle being replaced
Vehicle Safety Features - SELECT ALL THAT APPY
*
NONE
Forward Crash Avoidance
Adaptive Headlights
Backup Warning
Lane Departure / Blind Spot Monitoring
Driver Fatigue Sensing
Autonomous Operation Mode
Replaced Vehicle
Replaced Vehicle Date Traded / Sold / Donated
-
Month
-
Day
Year
Date
Most Regular Driver
*
Other Comments or Questions - Specific Coverage Requests
Upload any documents needed.
Browse Files
Drag and drop files here
Choose a file
Title, Lienholder or Lease Info
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Please keep in mind that changes to your insurance policy are not in force until confirmed. If you have questions about coverage selection or other issues pertaining to this change, please contact Cheryl at 952-953-3838 X3 or Cheryl@insurewithbutler.com
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