Personal Lines Service Request Name(Required) First Last Email(Required) Phone(Required)Which Personal Lines request would you like to make?(Required)SelectAdd/Remove an Additional InsuredAdd/Remove CoverageAdd/Remove a DriverAdd/Remove/Replace a VehicleCancellation RequestFile a ClaimRequest an ID CardGeneral InquiryAre you adding or removing an additional insured?(Required) Adding Removing Please enter the name of the additional insured you wish to add, the policy to which they should be added, and indicate the reason they are being added:(Required)Please enter the name of the additional insured you wish to remove and indicate the reason they are being removed:(Required)Are you adding or removing coverage?(Required) Adding Removing Please describe the coverage you are requesting to be added and the effective date you are requesting:(Required)Please describe the coverage you are requesting to be removed and the effective date you are requesting:(Required)Are you adding or removing a driver?(Required) Adding Removing Is this a youthful driver (under 25)?(Required) Yes No Is this driver currently enrolled in school and has a GPA of 3.0 or higher?(Required) Yes No Please enter the name, date of birth, driver's license number, and primary vehicle for the new driver below:(Required)Will this driver still remain in the household?(Required) Yes No Please enter the name and date of birth for the driver below:(Required)Are you adding, removing, or replacing a vehicle?(Required) Adding Removing Replacing Date of purchase:(Required)Year, make, and model:(Required)VIN:(Required)Current odometer reading:(Required)Who will be the primary driver:(Required)Primary usage:(Required) Pleasure Commute Business Farm Other Estimated annual mileage:(Required)Estimated mileage one way of commute to work or school:(Required)Describe the nature of the business and the vehicle's usage in such:(Required)Is the vehicle used for delivery?(Required) Yes No Delivery radius:(Required)Please describe the usage:(Required)Is this vehicle owned, financed, or leased?(Required) Owned Financed Leased Please enter the bank information:(Required)Which vehicle is being removed?(Required)Date of removal?(Required)Which vehicle is being removed for the replacement?(Required)Date of removal for the replacement?(Required)Date of purchase of the replacement vehicle:(Required)Year, make, and model of the replacement vehicle:(Required)VIN of the replacement vehicle:(Required)Current odometer reading of the replacement vehicle:(Required)Who will be the primary driver of the replacement vehicle:(Required)Primary usage of the replacement vehicle:(Required) Pleasure Commute Business Farm Other Estimated annual mileage of the replacement vehicle:(Required)Estimated mileage one way of commute to work or school of the replacement vehicle:(Required)Describe the nature of the business and the replacement vehicle's usage in such:(Required)Is the replacement vehicle used for delivery?(Required) Yes No Delivery radius of the replacement vehicle:(Required)Please describe the usage of the replacement vehicle:(Required)Is this replacement vehicle owned, financed, or leased?(Required) Owned Financed Leased Please enter the bank information of the replacement vehicle:(Required)Please enter the policy number for the policy you wish to make a claim on:(Required)Please briefly describe the nature of the claim you wish to make:(Required)Please enter the policy number for the policy you are requesting be cancelled:(Required)Briefly describe the reason for cancellation including the effective date:(Required)Please describe your request below. Include any pertinent information such as policy numbers and effective dates for changes to be made:(Required)Policy number for the ID Card request:(Required)
