Insurance Auto Change Summary

INSURANCE AUTO CHANGE SUMMARY

Policy and Insured Information

Policy Number:    Effective Date of Change:

Date of Birth:    Phone:    Email:

Summary of Requested Changes

Check all that apply and complete corresponding detail sections below:

Add vehicle    Remove vehicle    Change vehicle details
Add driver    Remove driver    Change coverage limits / coverages
Change deductible    Change address    Other (describe below)

Vehicle Details (Add / Remove / Change)

Provide each affected vehicle. Use additional pages if necessary.

VIN:    Plate / Reg.:    Use Type:

VIN:    Plate / Reg.:

Driver Details (Add / Remove)

List drivers to be added or removed. Include date of birth and driver license information.

Date of Birth:    Driver License #:    State Issued:

Date of Birth:    Driver License #:

Coverage Changes

Select coverages to modify and indicate new limits or deductibles where applicable.

Liability — New Bodily Injury / Property Damage limits: $
Collision — New deductible: $
Comprehensive — New deductible: $
Uninsured / Underinsured Motorist — Limit: $
Medical Payments — Limit: $
Rental reimbursement — Daily limit: $

Premium Adjustment and Billing

Estimated premium change: $    Prorated charge / credit: $    Reason for change:

Requested billing instruction:

Required Documentation Checklist

Please indicate documents provided to support this change (check all submitted):

Vehicle registration    Title / proof of ownership    Driver license copy
Prior insurance declaration    Police report (if applicable)    Other documents attached

Exclusions, Endorsements and Underwriting

This Insurance Auto Change Summary records the insured's requested changes. It is not a policy endorsement and does not bind coverage. All requested changes are subject to underwriting review, verification of documents and issuance of an official endorsement by the insurer. The insurer reserves the right to accept, modify or decline requested changes in accordance with policy terms, underwriting rules and applicable law. Any coverage provided prior to issuance of an endorsement is subject to policy terms, conditions, exclusions and limits.

By signing below the insured acknowledges that: (a) the information submitted is complete and accurate to the best of the insured's knowledge; (b) the insured is authorized to request the changes indicated; (c) knowingly providing false or misleading information may result in denial of coverage, cancellation or rescission of the policy and may subject the insured to civil or criminal penalties; and (d) any premium adjustments resulting from these changes may be billed or credited in accordance with policy provisions.

Beneficiary Designation (If Applicable)

Designation applies only to coverages that permit a beneficiary designation (for example, certain personal injury or death benefits). Complete only if a beneficiary designation is required for the indicated coverage.

Relationship:    Allocation Percentage: %

Additional Remarks

Applicant Certification

I certify that the information provided on this Insurance Auto Change Summary is true and complete. I acknowledge that the insurer may verify information and request additional documentation. I authorize the insurer and its agents to make any inquiries necessary to process this request. I understand that coverage changes are effective only when the insurer issues a written endorsement or other official notice confirming acceptance of the requested changes, unless otherwise agreed in writing.

Sign Now