Date

Your Company Name

Address (including Zip Code)

Name of individual requesting change

Effective Date of Change

Delete the following vehicle:
Year: Make:
Model:

Add the following vehicle:
Year:   Make:
Model:
Vehicle Identification #:
 

Cost of New Vehicle: $

Gross Vehicle Weight (trucks):
pounds

Comprehensive Coverage Desired:
Yes No Deductible $

Collision Coverage Desired:
Yes No Deductible $

Loss Payee (financing institution)
name and address:

If Vehicle leased, name & address of
leasing company:

Does lessor want to be named as
additional insured?  yes no