Policy Changes

Name*

First Last

Your Email Address*

Change of Address

What is the effective date of change?*

Please enter your new address:*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

Please select all of the following that pertains to this address change:*

Change of Physical Address

Change of Mailing Address

This is an ADDITIONAL Location

Special Instructions

Change of Coverage

What is the effective date of change?*

What policies below does this change pertain to?*

General Liability

Business Auto

Workers Compensation

Please state the changes that you would like to make on the above policy:*

Add/Delete Driver

What is the effective date of change?

To ADD a driver, please provide the following:

Driver's Name

Driver's License #

Driver's License State

Date of Birth

To DELETE a driver, please provide the following:

Driver's Name

Driver's License #

Driver's License State

Date of Birth

Special Instructions

Add/Delete Vehicle

What is the effective date of change?

To DELETE a vehicle, please provide the following:

Vehicle Year

Vehicle Make

Model

Vehicle VIN

To ADD a vehicle, please provide the following:

Complete Vehicle Identification Number

Vehicle Year

Vehicle Make

Vehicle Model

Garaging Zip Code (Where is this car parked at night?)

Will vehicle be driven locally (50-100 mile radius)?

Yes

How is this vehicle used?

Solely for business

Solely for personal use

Combination of both

Cost New of Vehicle (What was the car sold for brand new?)

Body Type (Truck? Private Passenger Car? SUV?)

Trailer Hitch? 5th Wheel Hitch?

Any permanently installed equipment on vehicle? If yes, please list equipment and value:

Desired Coverage (choose one)

Full coverage as already reflected on the other vehicles on the policy

Liability only as already reflected on the other vehicles on the policy

If not or only vehicle with full coverage, please list desired deductible for comprehensive and collision coverage:

Special Instructions:

By signing and typing your name below, you are authorizing changes to your policy.

Signature*

CAPTCHA

This information is not an offer to sell insurance. Insurance coverage cannot be bound or changed via submission of this online form/application, e-mail, voice mail or facsimile. No binder, insurance policy, change, addition, and/or deletion to insurance coverage goes into effect until you have received written confirmation from a licensed agent at DJM Insurance Services. Note any proposal of insurance we may present to you will be based upon the values developed and exposures to loss disclosed to us on this online form/application and/or in communications with us. All coverages are subject to the terms, conditions and exclusions of the actual policy issued. Not all policies or coverages are available in every state. You also agree to release us from any liability if this information is accidentally viewed by unauthorized persons. We will only use this information for insurance quoting purposes and not distribute to other parties.

Name

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

Change of Address

Change of Coverage

Add/Delete Driver

Add/Delete Vehicle

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(866) 961-4570

Lakeside Office