Change Form Testing

Vehicle Change Request (2)

"*" indicates required fields

Step 1 of 3

33%

Is this a dealer making the change or the insured?

Dealer

Insured

Effective Date of Change*

MM slash DD slash YYYY

Check this box if quote only, do not process change.

Quote Only

Dealer's Name & Phone Number*

Policy Holder Name*

First Middle Last

Policy Number (Not Required)

Is this change for a personal or business auto policy?

Personal

Business

Business Name (If Applicable)

Please Indicate Changes to Make

Replace a Vehicle

Add a Vehicle

Remove a Vehicle

An FS-6 form is required to remove a vehicle per NYS Law*

A copy of the FS-6 is attached to the client's account

Year, Make, & Model of vehicle being removed*

Will the plates be transferred?*

Yes

Year, Make and Model of Vehicle Being Added*

VIN of Vehicle Being Added*

Any vehicle modifications/ special equipment (Plows, toolbox, stereo, ect.)?

Yes

What are the modifications and costs?

What is the equipment and Value

Gross Vehicle Weight*

Vehicle Value*

Who will the vehicle be titled to?*

Who will the vehicle be registered to?*

Will there be a lienholder?*

Yes

Is it a lease?*

Yes

Name of Lienholder*

Address of Lienholder*

Street Address Address Line 2 City State ZIP Code

Where should we send the ID cards?*

Email*

Fax*

Client's Phone (For Confirmation)

Insured Questions- You Must Now Confirm All Changes With the Insured Before Processing Change or Sending Dealer Any Requested Documents

Would you like physical damage coverage?*

Comprehensive Deductible*

Collision*

Do you want Roadside Assistance coverage (towing)?*

Same As Vehicle Being Replaced (if a replacement vehicle)

Yes

Do you want rental reimbursement coverage?

Same As Vehicle Being Replaced (if replacement vehicle)

Yes

Who is the primary driver of vehicle?*

Do we need to add any additional drivers to the policy?*

Yes

Name

First Middle Last

Date of Birth

Month

Day

Year

Marital Status

License Number

Years Licensed

What is the main vehicle use?*

Commute to Work or School

Pleasure

Business

How many miles to work or school (one way)?

What is the reason for pleasure use? (Retired, Homemaker, Work from home)

Estimated miles driven per year?*

Is used for Rideshare (Uber, Lyft, ect.)?*

Yes

Is vehicle used for any kind of delivery or business?*

Yes

Is a CARCO required?

Yes

Why is CARCO not required?*

Vehicle is more than 7 years old (8 for Progressive)

Vehicle is new and MSO/Bill of Sale attached/requested.

Been with carrier for more than 2 years (Erie, Kemper, MSA, Preferred, Harley)

Been with carrier for more than 4 years (Progressive)

No physical damage coverage

Photo Inspection Acknowledgment Form Agreement*

I understand that I have been informed that my vehicle which is being insured for Collision and/or Comprehensive Coverage must be inspected by a representative of the insurer. This inspection must be completed within 14 calendar days after the effective date of coverage to avoid a suspension in coverage. I understand that failure to obtain the required inspection(s) will result in the suspension (losses will not be covered) of physical damage coverage as of 12:01 A.M. of the day following the date the inspection must be completed by.

Has the Named Insured confirmed all changes?*

Yes

No (Change cannot be made and no ID cards can be issued until all changes are confirmed by NI and confirmation is documented in Hawksoft)

Client Email for Copy of Change

Agent*

April

Becky

Bill

Cheyenne

Dale-Lynne

Desiraeh

Diane

Joshua

Keith

Lexus

Lisa

Neil

Tish

Vicki

Notebox

Effective Date of Change*

MM slash DD slash YYYY

Check this box if quote only, do not process change.

Quote Only

Policy Holder Name*

First Middle Last

Is this change for a personal or business auto policy?

Personal

Business

Business Name (If Applicable)

Please Indicate Changes to Make

Replace a Vehicle

Add a Vehicle

Remove a Vehicle

An FS-6 form is required to remove a vehicle per NYS Law*

A copy of the FS-6 is attached to the client's account

Year, Make, & Model of vehicle being removed*

Will the plates be transferred?*

Yes

Year, Make and Model of Vehicle Being Added*

VIN of Vehicle Being Added*

Any vehicle modifications/ special equipment (Plows, toolbox, stereo, ect.)?

Yes

What is the equipment and Value

Gross Vehicle Weight*

Vehicle Value*

Who will the vehicle be registered to?*

Who will the vehicle be titled to?*

Who is the primary driver of vehicle?*

Do we need to add any additional drivers to the policy?*

Yes

Name

First Middle Last

Date of Birth

Month

Day

Year

License Number

Marital Status

Years Licensed

What is the main vehicle use?*

Commute to Work or School

Pleasure

Business

How many miles to work or school (one way)?

What is the reason for pleasure use? (Retired, Homemaker, Work from home)

Is used for Rideshare (Uber, Lyft, ect.)?*

Yes

Is vehicle used for any kind of delivery or business?*

Yes

Will there be a lienholder?*

Yes

Is it a lease?*

Yes

Name of Lienholder*

Address of Lienholder*

Street Address Address Line 2 City State ZIP Code

Would you like physical damage coverage?*

Comprehensive Deductible*

Collision*

Do you want Roadside Assistance coverage (towing)?*

Same As Vehicle Being Replaced (if a replacement vehicle)

Yes

Do you want rental reimbursement coverage?

Same As Vehicle Being Replaced (if replacement vehicle)

Yes

Is a CARCO required?

Yes

Why is CARCO not required?*

Vehicle is more than 7 years old (8 for Progressive)

Vehicle is new and MSO/Bill of Sale attached/requested.

Been with carrier for more than 2 years (Erie, Kemper, MSA, Preferred, Harley)

Been with carrier for more than 4 years (Progressive)

No physical damage coverage

Photo Inspection Acknowledgment Form Agreement*

Where should we send the ID cards?*

Email (For ID Cards)*

Fax*

Client Email for Copy of Change

Agent*

April

Becky

Bill

Cheyenne

Dale-Lynne

Desiraeh

Diane

Joshua

Keith

Lexus

Lisa

Neil

Tish

Vicki

Notebox

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Vehicle Change Request (2)

Insured Questions- You Must Now Confirm All Changes With the Insured Before Processing Change or Sending Dealer Any Requested Documents

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