| GENERAL INFORMATION: |
| *Insured name: |
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| *Phone number: |
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| *E-mail Address |
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| *Policy number: |
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| Purchase/title date: |
Mo.
Day
Year
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| Sold/tags turned in date: |
Mo.
Day
Year
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| VEHICLE INFORMATION : |
| Vehicle 1: |
*Add or delete: |
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*Year: |
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*Make: |
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*Model: |
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| *Vehicle Identification Number: |
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*Anti-lock Brakes: |
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| *Primary Driver Name: |
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*Vehicle Usage: |
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*If commuting,
number of miles one way: |
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*If commuting,
number of days per week: |
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| *Annual Mileage: |
(average is 10-15,000) |
| *Airbags: |
Driver
Passenger
Side
All |
| *Anti-theft device: |
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| *Name on Vehicle Title: |
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| Lienholder Name: |
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| Lienholder Address: |
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| Vehicle 2: |
Add or delete: |
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Year: |
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Make: |
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Model: |
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| Vehicle Identification Number: |
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Anti-lock Brakes: |
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| Primary Driver Name: |
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Vehicle Usage: |
|
If commuting,
number of miles one way: |
|
If commuting,
number of days per week: |
|
| Annual Mileage: |
(average is 10-15,000) |
| Airbags: |
Driver
Passenger
Side
All |
| Anti-theft device: |
|
| Name on Vehicle Title: |
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| Lienholder Name: |
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| Lienholder Address: |
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| COVERAGES -
Please select the coverages you would like on your quote: |
| *Liability: |
Keep current coverages
Make changes below |
| Change Bodily Injury: |
$50,000/$100,000
$100,000/$300,000
$250,000/$500,000 |
| Change Property Damage: |
$50,000
$100,000 |
| Change Medical Expense: |
$1,000
$2,000
$5,000
$10,000 |
| Change Loss of Income: |
Yes
No |
Change Uninsured
Motorist Bodily Injury: |
$50,000/$100,000
$100,000/$300,000
$250,000/$500,000 |
Change Uninsured Motorist
Property Damage: |
$50,000
$100,000 |
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| Vehicle 1 other coverages: |
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| *Comprehensive Deductible: |
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| *Collision Deductible: |
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| Rental
Reimbursement: |
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Towing: |
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| Vehicle 2 other coverages: |
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| Comprehensive Deductible: |
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| Collision Deductible: |
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| Rental
Reimbursement: |
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Towing: |
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Additional Coverages needed
and/or additional comments: |
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I understand that NO changes to my policy or coverage are bound by submitting this online Policy Change Request.
This change request will be considered bound ONLY upon confirmation from my LIA agent.
I have read and agree with the above.
(Box must be checked before request is sent)
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