Berends Hendricks Stuit Insurance Agency, Inc. ::: Auto Insurance Change Request

Please Note: We cannot bind coverage from an email or voicemail request. Coverage is bound after you receive a written email or telephone confirmation from an agency staff member within 24 hours.

Auto Insurance Change Request Form

Effective date of change:

Name:

Phone:

Ext

Email:

Delete a Vehicle

Year:

Make and Model:

VIN:

Reason for deleting vehicle:

Sold

Stored

Traded

Other

Add a Vehicle

Year:

Make and Model:

VIN:

Owner:

Primary Driver:

Describe use:

Coverage Changes to New Vehicle

Coverage Requested:

Same coverage as deleted vehicle

See additional coverage selections below

Additional Coverages

Please use Other Comments area below for any desire coverage not listed here.

Towing:

Yes
No

Rental Reimbursement:

Note: You must have collision coverage in order to select Rental Reimbursement.

Yes
No

Loan/lease Gap:

Note: Your vehicle can be no more than 3 years old to be eligible for this coverage.

Yes
No

Anti-Lock Breaks:

Yes
No

Anti-Theft Alarm:

Yes
No

Airbags:

Driver side
Both Driver and Passenger side
Neither

Loan/lease Information (if applicable)

Bank Loan

Leaseholder

None

Other

Name of Loan/Leaseholder:

Address:

City, State, Zip:

Change in Loan/Leaseholder Status

Add
Change
Delete

Name of Loan/Leaseholder:

Address:

City, State, Zip:

Inquiry or Additional Comments: