Change: Replace Vehicle

Replace Vehicle

"*" indicates required fields

Vehicle to Remove

Date to Remove Vehicle*

Vehicle to be Removed*

Reason for Removal*

Traded In

Sold

Insured Elsewhere (must provide details below)

No Longer Operational

Parked / Garaged

Selling Vehicle

Totaled from Claim

Other

Vehicle to Add

Was this vehicle purchased Brand New or Used?*

Brand New

Used

Purchase Date*

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?*

Yes

No

List existing damage*

Does this vehicle have Branded or Salvage Title?*

Yes

No

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.

Financing Information

Finance Company Name*

Leasing Company Name*

Address

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.)?*

Yes

No

Provide details about Rideshare usage*

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

Yes

No

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*

Internal Use Only

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Internal Use

Yes

Person completing this form*

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

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

Replace Vehicle

Replace Vehicle

Vehicle to Remove

Vehicle to Add

Financing Information

Vehicle Use

Coverage Options

Contact Info

Internal Use Only

End