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Disclaimer:
I understand that my coverage (or changes in coverage) ARE NOT binding via this on-line request; Changes ARE considered binding when I receive an email (or fax) response from my agent indicating that they have received my request.
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I have read and agree with the above
(Box must be checked before request can be sent) |
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Policy Holder Information: |
Name Insured: |
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Phone Number: |
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Email: |
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Policy Number: |
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Effective Date of Change: |
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If Adding a Vehicle: |
Year: |
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Make: |
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Model: |
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Vehicle Identification Number (VIN): |
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Cost: |
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Anti-Lock Brakes: |
Yes
No |
Air Bags: |
None
Driver
Driver/Passenger |
Anti-Theft Device: |
Yes
No |
How will car be driven? (Check One): |
Farm
To/From Work
In Business
Car Pool
Pleasure |
Miles One Way to Work: |
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Primary Driver: |
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Relationship to Insured: |
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Driver's License No.: |
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Date of Birth: |
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Defensive Driving Certificate? |
Yes
No |
Drivers Training Certificate? |
Yes
No |
Comp Coverage? |
Yes
No |
Coll Coverage? |
Yes
No |
Towing? |
Yes
No |
Rental? |
Yes
No |
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If Deleting a Vehicle: |
Effective Date of Change: |
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Year: |
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Make: |
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Model: |
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VIN Number: |
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If Deleting a Driver: |
Name: |
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Reason:
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