Vehicle Add/Replace Change Request Form
Would you prefer to submit a photo of the VIN (Vehicle Identification Number) or type info?
I will type the info
I will take a photo of the Vehicle ID Number
Year, Make and Model of vehicle to be added
Please type the VIN below.
How is the new vehicle titled? (List the Name(s) of Owners and or Entity such as a trust, LLC, etc as listed on the Title Application).
Example: John and Jane Doe; John Sr. and John Jr. Doe; The Doe Family Trust.
Who will be the primary driver of the vehicle?
Commute to Work or School
How Many Miles Is this Vehicle Driven ONE WAY to Work or School?
Does this vehicle have any of the following (check all that apply):
Automatic Braking System (automatically activates the vehicle's brake system, to some degree, when necessary)
Non-factory customization (conversion van, medical lift, chrome rims, tonneau cover, special paint job, etc
Please describe the non-factory customization and the value of the customization.
When determining value of a vehicle at the time of a claim, the insurance company does not figure in non-factory customization unless we add specific coverage.
Match coverage to my existing vehicle
Liability Only (no coverage for any damage to the vehicle itself)
Liability, comprehensive and collision (we will match your current comprehensive and collision deductibles if applicable. If you do not have comprehensive or collision deductibles we will use $250 for comprehensive and $500 for collision. If you want other deductibles, please note it in the comment section below.)
Comprehensive only (aka "storage coverage")
Uncertain, please contact me with options
Which vehicle's coverage would you like to match?
Optional Coverage (if you selected "match coverage" above, you may skip this section if you want to keep the same optional coverage that you already have). Please note: not all optional coverages are available from all insurance companies.
$0 Glass Deductible (Waives your deductible for any glass claims)
Towing or Roadside Assistance
Rental Reimbursement (coverage for a rental car while yours is being repaired due to a claim)
Loan/Lease Gap Coverage (good to add if you will ever owe more on your vehicle than what it is worth
Rented Car Gap Coverage (provides coverage for loss of use and diminished value when you rent a vehicle). Not available with all companies.
New Parts Coverage (brand new parts from manufacturer versus after market parts)
Replacement Cost Coverage (available on brand-new vehicles only)
Loan Payoff (A life insurance product to help payoff the vehicle loan)
Accident or Violation Forgiveness (not available with all companies)
What date are you purchasing this vehicle?
Date Picker Icon
How are you paying for the vehicle?
Please Provide Name/Address of Lending Institution (Bank/Credit Union). This can typically be found on the paperwork you received from the dealership.
Please Provide Name/Address of the Leasing Company. This can typically be found on the paperwork you received from the dealership.
Will you be selling or trading in a vehicle?
Which vehicle will you be selling or trading in?
What date will the other vehicle be sold or traded in? Please note, it is very important that you do NOT remove coverage until the title is officially out of your name. We recommend keeping a copy of the signed title as well as a signed receipt if you are selling to a private party.
Date Picker Icon
Please Check Any That Apply:
NONE OF THESE APPLY
I would like prices to increase my Liability or Uninsured/Underinsured Motorist Coverage. (We will process this change with current coverage limits and send you updated quotes in a few business days).
One or more of my vehicles has a salvage title.
One or more of my vehicles is NOT primarily kept at my home address.
One or more of my vehicles is used for hazardous activities (racing, demolition derby, etc.)
A member of my household drives for hire (such as Uber, Lyft, Shipt, pizza delivery, etc.)
A member of my household has a "company car."
Which vehicle(s) have a salvage title?
Which vehicle(s) are not primarily kept at your home address? Please list the vehicle(s) and list the address where they are typically kept.
Which vehicle(s) are used for hazardous activities? Please describe the activities and which driver(s) participate in the hazardous activities.
Which vehicle(s) are used for driving for hire activities Uber, Lyft, Shipt, pizza delivery, etc.? Please describe the activities and which driver(s) are driving for hire.
Which driver has a company vehicle?
Please provide the names of all members of your household (including non-drivers). We want to confirm that we aren't missing anyone. First name is fine.
How would you prefer to be contacted if we have additional questions?
Please provide any specific instructions, questions or concerns.
Signature (On laptop/PC use your mouse. On a mobile device use stylus or finger.
Should be Empty: