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Customer Vehicle Change Request Form

Protecting you on the road.

Vehicle Change Request Form

Home » Customer Vehicle Change Request Form

We’ll make sure you have the auto protection you need at a price you can afford.

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"*" indicates required fields

This field is for validation purposes and should be left unchanged.

Please provide the insured's first name, last name, email address, and phone number:

Name

First Name Last Name

Phone

Phone Type

What vehicle are you looking to insure?

Make

Year

Model

VIN*

Please enter 17-digit VIN number.

What date do you need the insurance to start on the new vehicle?

MM slash DD slash YYYY What date do you need the insurance to start on the new vehicle?

Who’s name will this vehicle be registered to?

First Name Middle Name Last Name

It is imperative that the name on this ID Card matches how their name reads on their Driver’s License. Please be sure to include the name(s) exactly as it appears on the driver’s license. Failure to provide accurate information may result in a delay in receiving your ID Cards.

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Who’s name will this vehicle be registered to?

Is there a loan or lease on this vehicle?

Yes – Loan

Yes - Lease

Neither

Please provide the lienholder/lessee name and address how they want to be listed on your policy.*

What safety features does this vehicle have?

ABS Brakes

Yes

Daytime Running Lights

Yes

Airbags

Yes

Anti-theft

Yes

Where are airbags located?

Driver's Side

Passenger Side

Both

Type of anti-theft

Active

Passive

Audible

VIN/Window Etching

Yes

Electronic Tracking Device (GPS)

Yes

Who will be the primary operator of this vehicle?

Please provide first and last name.*

Are you transferring plates from another vehicle to this new vehicle?

Yes

Which vehicle are you transferring plates from?

Year

Make

Model

Last 4 numbers of VIN*

Is the vehicle, which the plates that are being transferred from, being sold or traded in?

Yes

Are you purchasing this vehicle from a dealer?

Yes

Dealership Information

Dealership Name

Contact Name

Phone

Fax

Where should the Insurance Binder & Auto ID cards be sent?

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Where should the Insurance Binder & Auto ID cards be sent?

State

Fax

Customer Vehicle Change Request - Man Standing Behind Driver's Seat Door Car With Tree Shadows Wooded Background

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As an independent agency, we are here to help you find the right auto coverage.

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Liverpool, NY Office

8035 Oswego Road
Liverpool, NY 13090

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Insurance Quote Request

As an independent agency, we are here to help you find the right coverage.

This field is for validation purposes and should be left unchanged.
This field is for validation purposes and should be left unchanged.
Name
First Name Last Name
Email
Email
Phone Number
Phone Number
How can we help?
How can we help?

Customer Vehicle Change Request Form

Protecting you on the road.

Vehicle Change Request Form

We’ll make sure you have the auto protection you need at a price you can afford.

Please provide the insured's first name, last name, email address, and phone number:

What vehicle are you looking to insure?

What safety features does this vehicle have?

Who will be the primary operator of this vehicle?

Which vehicle are you transferring plates from?

Dealership Information

Where should the Insurance Binder & Auto ID cards be sent?

Get Started Today

Contact Us

Liverpool, NY Office

Follow Us on Social Media

Insurance Quote Request

Get a Quote

It only takes a minute to get started.

Would you rather discuss this in person? Get in touch with an agent today!

Contact Us

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