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Vehicle Change Request
Requested By:
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Date
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Name of Company:
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Requested Date of Change:
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Vehicle 1
Check Appropriate Box
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Add
Delete
Change
How is vehicle titled (Name on title)?
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Vehicle Year, Make, & Model:
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VIN:
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Gross Vehicle Weight (GVW):
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Cost New:
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Description of Special Equipment:
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Total Value of Vehicle (Cost + Special Equipment):
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How is Vehicle Used?
Principal Place of Garaging:
Distance Vehicle is driven:
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Local (0-50 Miles)
Intermediate (50-200 Miles)
Long Haul (200+ Miles)
Vehicle Driven By:
Coverage Elections:
*
Liability
Physical Damage