Change: Add Vehicle

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Change: Add VehicleMatthias Allred2024-06-25T16:40:31-06:00

Policy Change: Add Vehicle

"*" indicates required fields

Vehicle Details

Was this vehicle purchased Brand New or Used?*

Brand New

Used

Purchase Date*

MM slash DD slash YYYY

Year*

Make*

Model / Trim level*

VIN*

Verify the VIN by using: VehicleHistory.com

Sticker Price*

Odometer Reading*

Who will the Vehicle be titled to?*

Does this vehicle have any existing damage?*

No

Yes

List existing damage*

Does this vehicle have Branded or Salvage Title?*

No

Yes

Is there a Loan or Lease on the vehicle?*

Financed

Leased

No, Paid Cash

Upload Vehicle Documentation

Drop files here or

Accepted file types: pdf, jpg, jpeg, jpg, png, gif, Max. file size: 12 MB, Max. files: 5.

Comments or Notes

Financing Information

Finance Company Name*

Leasing Company Name*

Address

Street Address Address Line 2 City State Zip Code

Would you like GAP coverage if available?*

Yes I do

Let me know how much first.

No I do not.

Supporting Finance Documents

Drop files here or

Max. file size: 128 MB.

Vehicle Use

Who will be the primary driver?*

How will the vehicle be used?*

Commute

Business

Pleasure (extra car)

How many miles do you commute one direction?*

Estimated Annual Miles driven?*

Is this Vehicle Used for Rideshare (Uber, Lyft, etc.)?*

No

Yes

Provide details about Rideshare usage*

Is this Vehicle Used for any kind of delivery (Newspaper, Pizza, etc)?*

No

Yes

Provide details about delivery usage*

Coverage Options

Comprehensive Deductible*

Collision Deductible*

Do you want Rental Car reimbursement coverage?*

Yes

No

Do you want Roadside Assistance Coverage?*

Yes

No

Do you want Full Glass Coverage (if available)*

Yes

No

Contact Info

First Name*

Last Name*

Cell Phone*

Email*

Consent*

Change Approval Required*

I understand that no changes will go into effect until an agent has reviewed the request to make sure it complies with my insurance company's underwriting guidelines and the change has been accepted by the company.

Internal Use Only

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Internal Use

Yes

Person completing this form*

Matthias

Todd

Laura

IJ

Jenniea

Agent Email

Method request was received*

Phone Call

Email

Text Message

Chat / Messenger

Ezlynx Notification

Facebook

Agent Generated

Other

Additional Notes / Instructions

Task Due Date

MM slash DD slash YYYY

Task Assignee

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Task Assignee AMS User ID

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Task Assignee Email

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AMS ID

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CRM ID

End

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