Berends Hendricks Stuit Insurance Agency, Inc. ::: Policy 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.

Contact Information

Effective date of change:

Insured Name:

Phone:

Ext

Email:

Change Your Commercial Auto Policy

Add or Delete a Driver

Add a driver
Delete a driver

First Name:

Middle Name:

Last Name:

Date of Birth:

Drivers License Number:

State Issued:

Add or Delete a Vehicle

Add a vehicle
Delete a vehicle

Make:

Model:

Year:

VIN:

Cost, New:

Titleholder/leaseholder:

Lien Holder Information

Name:

Address:

City, State, Zip:

Gross Vehicle Weight:

Vehicle Use:

Garage Information:

Location:

Address:

City, State, Zip:

General Policy Change

Policy Type:

Commercial Property/Casualty
Commercial Auto
Workers Compensation

Other

Description of Change:

Comments of Additional Information: