Berends, Hendricks, & Stuit Insurance Agency, Inc. :: Client Services :: Personal Lines

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Client Services :: Personal Lines :: 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.

Effective date of change:
Name:
Enter your phone number (if you would prefer us to contact you by phone):	Ext:
Enter your email address (Required):

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:
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