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Policy Auto Change Request Form
Person Requesting Change*
Policy Holder Name*
First Last
Email*
Cell Phone*
Policy # (if known)
Changes to Make
Please indicate the changes to be made*
- Replace a Vehicle
- Add a Vehicle
- Remove a Vehicle
- Add a Driver
- Remove a Driver
- Update Loan/Lease Info
- Change Coverages on a Vehicle
- Change Mailing/Garage Address
- Other
Replace a Vehicle
remove a vehicle, add a vehicle
Date Vehicle to be Replaced*
MM slash DD slash YYYY
Vehicle to be Removed*
Reason for Removal*
- Traded in
- Sold
- No longer operational
- Parked / Garaged
Vehicle to be Added*
VIN*
Verify the VNN by using: Vehiclehistory.com, AutoDNA.com, or SearchQuarry.com
Who is the vehicle registered to?*
List the primary driver of the vehicle*
Vehicle Use*
- Commute to work or school
- Pleasure
- Used for Business
How many miles one way?*
Annual Miles*
Describe business use.*
vehicles used in a business or by salespersons, clergy, contractors, real estate agents, lawyers, doctors, accountants, reporters and similar occupations, visiting multiple locations.
Is this vehicle garaged at the Insured’s zip code?*
- Yes
- No
Garaging Address:*
Street Address City State Zip Code
Is this Vehicle Used for Rideshare (Uber, Lyft, etc.)*
- Yes
- No
Is this vehicle used for delivery?*
- Yes
- No
Does this vehicle have any existing damage?*
- Yes
- No
List existing damage*
Does the vehicle have a salvaged or rebuilt title?*
- Yes
- No
Do you want to Uninsured/Underinsured Motorist added (if not already on policy)?**
- Yes
- No
Do you want Personal Injury Protection coverage added (if not already on policy)?**
- Yes
- No
Comprehensive Deductible*
(required if you have a loan/lease)
Collision Deductible*
(required if you have a loan/lease)
Do you want Rental Car reimbursement coverage?*
(Available only if comprehension/collision are purchased)
- Yes
- No
Do you want Roadside Assistance Coverage?*
(Available only if comprehension/collision are purchased)
- Yes
- No
List holder Information*
- I have a loan on this vehicle
- This vehicle is a lease
- There is no loan or lease on this vehicle
Bank or Credit Union name (if known)
Bank or Credit Union address (if known)
Are you interested in GAP coverage?*
Available only if a vehicle has not been previously titled
- Yes
- No
Lease Company Name*
Lease company address*
Upload Vehicle Documentation
Please upload any documentation you have about your vehicle such as a purchase contract, registration information, etc.
Drop files here or

Max. file size: 128 MB.
Remove a Vehicle
Date Vehicle to be Removed*
MM slash DD slash YYYY
Vehicle to be Removed*
Reason for Removal*
- Traded in
- Sold
- No longer operational
- Parked / Garaged
Remove a Driver
Date driver to be Removed*
MM slash DD slash YYYY
Name of Driver to be Removed*
First Last
Driver's Date of Birth*
Month
Day
Year
Reason for Removal*
- No Longer in Household
- Away at College
- In the Military
- Has Own Insurance
- Other
Where will they be going to school?*
Will they be taking a car?*
- Yes
- No
Is the school more than 100 miles away?*
- Yes
- No
Where do they now live & when did they move?*
Do they still live in your house?*
- Yes
- No
When did they Start their Policy?*
Month
Day
Year
Please explain*
Has own insurance?*
- Yes
- No
Name of Insurance Company
Policy #
Effective Dates
MM slash DD slash YYYY
Current Liability Limits
Photo of declaration page (must show the limits of the policy)
Drop files here or

Max. file size: 128 MB.
Will they still have regular access to your vehicles?
- Yes
- No
How many times will they be using the vehicle per month?
Change Coverages on a Vehicle
The company will require a signed request to remove or lower coverage for the following: Bodily Injury Liability, Uninsured/Underinsured Motorists, Personal Injury Protection. An agent will reach out for further discussion.
Effective Date of Change*
MM slash DD slash YYYY
Which vehicle do you want to change coverage on*
What Changes do you want to make?*
- Change Comprehensive Deductible
- Change Collision Deductible
- Change Roadside Service
- Change Rental Car Reimbursement Coverage
- Change Personal Injury Protection (PIP)
- Change Uninsured Motorist (UM)
New Comprehensive Deductible*
New Collision Deductible*
New Liability Limits*
(an agent will reach out to review options)
Roadside Service*
(Available only if comprehension/collision are purchased) (aprox. $1/mo./veh)
Rental Car Coverage*
(Available only if comprehension/collision are purchased) (aprox. $6/mo./veh)
Personal Injury Protection Limits (PIP)*
Medical & Additional Benefits for you and your passengers
Uninsured/Underinsured Limits (UIM)*
Protection for when the other party doesn't have any or not enough insurance.
Add a Vehicle
Date Vehicle to be Added*
MM slash DD slash YYYY
Vehicle to be Added*
VIN*
Verify the VNN by using: VechileHistory.com, AutoDNA.com, or SearchQuarry.com
Who is the vehicle registered to?*
Vehicle Use*
- Commute to work or school
- Pleasure
- Used for Business
How many miles one way?*
How many miles per year?*
Describe business use.*
Estimated Miles Driven Per Year*
Is this vehicle garaged at the Insured’s zip code?*
- Yes
- No
Garaging Address:*
Street Address City State Zip Code
Who will be driving the vehicle on a regular basis?*
Is this Vehicle Used for Rideshare (Uber, Lyft, etc.)*
- Yes
- No
Is this vehicle used for delivery?*
- Yes
- No
Does this vehicle have any existing damage?*
- Yes
- No
Does the vehicle have a salvaged or rebuilt title?*
- Yes
- No
List existing damage*
Do you want to Uninsured Motorist added (if not already on policy)?**
- Yes
- No
Do you want Personal Injury Protection coverage added (if not already on policy)?**
- Yes
- No
Comprehensive Deductible*
(required if you have a loan/lease)
Collision Deductible*
(required if you have a loan/lease)
Do you want Rental Car reimbursement coverage?*
- Yes
- No
(Available only if comprehension/collision are purchased)
Do you want Roadside Assistance Coverage?*
- Yes
- No
(Available only if comprehension/collision are purchased)
List holder Information*
- I have a loan on this vehicle
- This vehicle is a lease
- There is no loan or lease on this vehicle
Bank or Credit Union name (if known)
Bank or Credit Union address (if known)
Are you interested in GAP coverage?*
- Yes
- No
Lease Company Name*
Lease company address*
Upload Vehicle Documentation
Drop files here or

Max. file size: 128 MB.
Please upload any documentation you have about your vehicle such as a purchase contract, registration information, etc.
Add a Driver
Date Driver to be Added*
MM slash DD slash YYYY
Name of Driver to be Added*
First Last
Does this person live at your address?*
- Yes
- No
What is their relationship to you?*
Marital Status?*
Date of Birth*
Month
Day
Year
Gender?*
Driver's License Number & State*
Social Security Number
Are we adding a young driver?*
- Yes
- No
Did the young driver take Drivers Education?*
- Yes
- No
Does he/she have an accumulative GPA of 3.0 or higher?*
- Yes
- No
Get the Discount
To keep the Good Student Discount: email or text a copy of the report card or transcript no later than 14 days to info@crossinsuranceagency.com
Do you want to upload the report card(s) now?*
- Yes
- No, I'll send it in later
Upload Report Card(s)
Max. file size: 128 MB.
All Tickets & Accidents: Please list all tickets received (paid for or not) the last 3 years and accidents (at fault or not) the last 5 years. Type ''None'' if none.
Date Tickets
Date Fault What Happened
Email or text the document to info@crossinsuranceagency.com
Update Loan/Lease Info
Car Loan Update Type*
- Current Loan/Lease - bank or credit union needs proof of insurance
- New Loan/Lease - update policy and send proof of insurance
- Paid off - Remove Loan/Lease info
Date of New Loan*
MM slash DD slash YYYY
Date to be Removed*
MM slash DD slash YYYY
Which Vehicle is the loan associated with?**
Company Name*
Account # (if needed)
Company Mailing Address
Street Address City State Zip
Company Email Address*
Loan or Lease?
Upload Car Loan Info
Drop files here or

Max. file size: 128 MB.
Change Mailing/Garage Address
Mailing address*
Street Address City State Zip Code
Are the vehicles garaged at the same location*
- Yes
- No
Garaging Address*
Street Address City State Zip Code
Additional Notes or Comments
Upload Supporting Documentation or Reports
Drop files here or

Max. file size: 128 MB.
Notice of Agreement*
- I understand that no changes will go into effect until an agent has reviewed the request to make sure it complies with our insurance company's underwriting guidelines and the change has been accepted by the company.
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CONTACT US

CENTRALIA OFFICE

Phone: (360) 330-2088
Email us
Address: 1206 Harrison Ave, Centralia, WA 98531
Hours: Monday–Friday
8:30 A.M. to 5:30 P.M.

OLYMPIA OFFICE

Phone: (360) 438-6708
Email us
Address: 2745 Martin Way E #A
Olympia, WA 98506
Hours: Monday–Friday
8:30 A.M. to 5:30 P.M.

MARYSVILLE OFFICE

Phone: (360) 659-3970
Email us
Address: 1914 4th Street
Marysville, WA 98270
Hours: Monday–Friday
8:30 A.M. to 5:30 P.M.

PORT ANGELES OFFICE

Phone: 360-457-4441
Email Us
Address: 102 E First St, Port Angeles WA 98362
Hours: Monday-Friday
8:30 A.M. – 5:30 P.M.

TACOMA OFFICE

Phone: (253) 475.5313
Email us
Address: 8031 Pacific Ave, Tacoma, WA 98408
Hours: Monday–Friday
8:30 A.M. to 5:30 P.M.

Locations

1206 Harrison Ave

Centralia, WA 98531

(360) 330-2088

1914 4th Street

Marysville, WA 98270

(360) 659-3970

2745 Martin Way E #A

Olympia, WA 98506

(360) 438-6708

102 E First St

Port Angeles, WA 98506

(360) 457-4441

8031 Pacific Ave

Tacoma, WA 98408

(253) 475-5313

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