AUTOMOBILE POLICY CHANGE REQUEST

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

I understand that my coverage (or changes in coverage) ARE NOT binding via this online 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

POLICY HOLDER INFORMATION
Name Insured:
Phone Number :
Email:
Effective Date of Change:
IF ADDING A VEHICLE:
Year:
Make:
Model:
Serial #:
Cost:
 $
Anti-Lock Brakes:
Air Bags:
Antitheft Device:
How will car be driven?
IF ADDING A DRIVER:
Name:
Relationship:
Drivers License #:
Date of Birth:
Social Security #:
Defensive Driving Certificate?
Drivers Training Certificate?
IF DELETING A VEHICLE:
Effective Date of Change:
Year:
Make:
Model:
Serial #:
IF DELETING A DRIVER:
Name:
Reason:

Click "submit" to send

 

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last updated 3-may-03