| Company Name: |
|
| Contact Name: |
|
| Contact Email: |
|
| Policy Number: |
|
| Phone: |
|
| Fax#: |
|
| Add/Delete Vehicle
(check one). Add: Delete: |
| Enter effective date of this
change: |
|
|
|
| If Adding or
Deleting a Vehicle Please provide the following information: |
| Description of Vehicle |
|
| Year:
Make: Model: |
COMPLETE VIN #:
(Must have complete VIN # or we can not process your
request) |
| Registered Owner: |
| Where Garaged:
(city, state, zip) |
| Driver: (check one)
Independent Contractor or
Employee |
| Cost new or value: |
|
| GVW (gross vehicle weight) |
|
Loss Payee/Additional
insured
(name/address): |
|
| Coverages Added: |
- Specified Perils
- Comprehensive
- Collision
|
