Commercial Auto Insurance change request

Lewis Insurance Associates now offers you the ability to make changes to your Commercial Auto Insurance using the form below.

( * indicates required information)

*Effective Date of change: Mo.   Day     Year
*Business Name:
*Contact Person:
*Policy Number :
*Phone Number:
*E-mail:
 
VEHICLE INFORMATION :
Vehicle 1: *Add or delete: Add     Delete *Year:
*Make: *Model:
*Vehicle Identification Number: *Cost new:
*Gross Vehicle Weight:
*Primary Driver Name:
*Vehicle Usage: Pleasure   Commute
*If commuting,
number of miles one way: 		 If commuting, number of days per week:
*Annual Mileage:
*Radius of Operations: Local (0-50 miles 1 way)
Intermediate (51-100 miles 1 way)
Long Distance (101 + miles 1 way)
*Name on Vehicle Title:
*Lienholder Name:
*Lienholder Address:
*Physical Garaging Address:
Value and description of any permanantly
attached equipment on the vehicle:
 
Vehicle 2: Add or delete: Add     Delete Year:
Make: Model:
Vehicle Identification Number: *Cost new:
Gross Vehicle Weight:
Primary Driver Name:
Vehicle Usage: Pleasure   Commute
If commuting,
number of miles one way: 		 If commuting, number of days per week:
Annual Mileage:
Radius of Operations: Local (0-50 miles 1 way)
Intermediate (51-100 miles 1 way)
Long Distance (101 + miles 1 way)
Name on Vehicle Title:
Lienholder Name:
Lienholder Address:
Physical Garaging Address:
Value and description of any permanantly attached equipment
on the vehicle:
Please list any additional information below:
Additional Information:
 

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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