Kouri Insurance Agency, Inc. -- Automobile Policy Change Request

AUTOMOBILE POLICY CHANGE REQUEST

Please use the form below to notify us of any changes to your automobile policy insured through this company/agency. Please note that this form is for notification purposes and any changes will not be binding until you receive confirmation from our company/agency.

Disclaimer

I understand that my coverage (or changes in coverage) ARE NOT binding via this on-line request; Changes ARE considered binding when I receive an email (or fax) response from my agent indicating that they have received my request.

	I have read and agree with the above disclaimer.
	(Box must be checked before request can be sent)

Policy Holder Information

Name Insured:

Phone #: E-Mail:

Effective Date
of Change:

IF ADDING a vehicle:

Year: Make

Model: Serial #:

Cost: $ Cost is needed for a trailer only

Coverage: Liability only Liability+comprehensive
Liability+comprehensive+collision

Financing: Name Leased? Yes No
Address
City State Zip

Anti-Lock Brakes: Yes No

Air Bags: None Driver Driver/Passenger

Anti-Theft Device: Yes No

How will car
be driven?
(Check One): Farm To/From Work In Business
Car Pool Pleasure

IF ADDING a driver:

Name:

Relationship: DL#:

Date of Birth: SS#:

Vehicle Driven:

Good Student
Discount? Yes, GPA of 3.0 or better No

Drivers Training
Certificate? Yes No

IF DELETING a vehicle:

Effective Date
of Change:

Year: Make:

Model: Serial #:

IF DELETING a driver:

Name:

Reason:

IF CHANGING a vehicle:

Year: Make:

Model:

Change Description:

Policy Holder Information
Name Insured:
Phone #:	E-Mail:
Effective Date of Change:

IF ADDING a vehicle:
Year:	Make
Model:	Serial #:
Cost:	$ Cost is needed for a trailer only
Coverage:	Liability only Liability+comprehensive Liability+comprehensive+collision
Financing:	Name Leased? Yes No Address City State Zip
Anti-Lock Brakes:	Yes No
Air Bags:	None Driver Driver/Passenger
Anti-Theft Device:	Yes No
How will car be driven? (Check One):	Farm To/From Work In Business Car Pool Pleasure

IF ADDING a driver:
Name:
Relationship:	DL#:
Date of Birth:	SS#:
Vehicle Driven:
Good Student Discount?	Yes, GPA of 3.0 or better No
Drivers Training Certificate?	Yes No

IF DELETING a vehicle:
Effective Date of Change:
Year:	Make:
Model:	Serial #:

IF CHANGING a vehicle:
Year:	Make:
Model:
Change Description: