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Auto Insurance Change Request

Please use the form below to notify us of any changes to your automobile policy insured through this company/agency. Please note this form is for notification purposes only. 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 e-mail (or fax or phone) response from my agent indicating that they have completed my request.
	I have read and agree with above disclaimer.
	Box must must be checked before request can be sent

Policy Holder Information: (* Required Information)

First Name:*		Last Name*:
Policy Number:*
Street Address:*		City:*
State:*		Zip Code:*
Social Security Number:		Birthday:
Immediate Phone (for urgent quotes):		Home Phone:*
Work Phone:	Extension:	FAX:
Email Address:*
If changing address:
New Street Address:		New City:
New State:		New Zip Code:
New Home Phone:		New Miles, One Way, to Work:
If adding a vehicle:
VIN: (if you do not know your VIN, just enter DO NOT KNOW)		Year:
Make:		Model:
Sub Model:		Body Style:
Number of Doors:		Cylinders:
Primary Driver:		4 Wheel Drive:
Turbo:		Anti-lock Brakes:
Automatic Seat Belts:		Driver Air Bag:
Passenger Air Bag:		Anti-theft:
Comprehensive:		Collision:
Do you have a lien on this automobile?:		Lien holder name and address:
Estimated Annual Miles Driven:		Zip Code of Garaged Location:
Primary Use:		Distance, One Way, to Work:
Days Per Week Vehicle is Used:		Is Vehicle Leased?
If deleting a vehicle:
Year:		Make:
Model:
If adding a driver:
First Name:		Last Name:
Age:		Birth Date (mm/dd/yy):
Gender:		Marital Status:
Texas Driver's License Number:
How many auto insurance claims have you made in the last 5 years?
Has your driver's license been suspended, cancelled or revoked in the past 7 years?
How many tickets have you had in the last 5 years?
How many accidents have you had in the last 5 years?
How many DUI/DWI convictions have you had in the last 7 years?
Have you ever had an SR-22 Filing? (An SR22 Filing is a form issued by an insurance company which removes a suspension order placed by the DMV on your driving privileges.)
Have you ever taken driver's education?
If deleting a driver:
First Name:		Last Name:
If changing coverage:
Year:		Make:
Model:
New Comprehensive:		New Collision:
Special Instructions:

ANY PERSON WHO, KNOWINGLY AND WITH INTENT TO DEFRAUD ANY INSURANCE COMPANY OR ANOTHER PERSON, FILES AN APPLICATION FOR INSURANCE CONTAINING ANY MATERIALLY FALSE INFORMAION, OR CONCEALS FOR THE PURPOSE OF MISLEADING INFORMATION CONCERNING ANY FACT MATERIAL THERETO, COMMITS A FRAUDULENT INSURANCE ACT, WHICH IS A CRIME AND SUBJECTS THE PERSON TO CRIMINAL AND CIVIL PENALTIES. BENEFITS MAY BE DENIED.


	© 2007 HIG - Henrich Insurance Group.	Comments, Questions Email Us