Vehicle -

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*

Vehicle to be Removed*

Reason for Removal*

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 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)

Are you interested in GAP coverage?*

Available only if a vehicle has not been previously titled

Yes
No

Lease Company Name*

Upload Vehicle Documentation

Please upload any documentation you have about your vehicle such as a purchase contract, registration information, etc.

Drop files here or

Remove a Vehicle

Date Vehicle to be Removed*

Vehicle to be Removed*

Reason for Removal*

Remove a Driver

Date driver to be Removed*

Name of Driver to be Removed*

First Last

Driver's Date of Birth*

MM

DD

YYYY

Reason for Removal*

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?*

MM

DD

YYYY

Please explain*

Has own insurance?*

Yes
No

Name of Insurance Company

Policy #

Effective Dates

Current Liability Limits

Photo of declaration page (must show the limits of the policy)

Drop files here or

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*

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*

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 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)

Are you interested in GAP coverage?*

Yes
No

Lease Company Name*

Upload Vehicle Documentation

Drop files here or

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*

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*

MM

DD

YYYY

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)

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*

Date to be Removed*

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

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

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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Policy Auto Change Request Form

Changes to Make

Replace a Vehicle

Remove a Vehicle

Remove a Driver

Change Coverages on a Vehicle

Add a Vehicle

Add a Driver

Get the Discount

Update Loan/Lease Info

Change Mailing/Garage Address

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