First Last Type of Change * Please Select Change of Address Change of Coverage Add/Delete Driver Add/Delete Vehicle Change of Address Please enter your new address: * Please select all of the following that pertains to this address change: * Change of Coverage What policies below does this change pertain to? * Please state the changes that you would like to make on the above policy: * Add/Delete Driver To ADD a driver, please provide the following: To DELETE a driver, please provide the following: Add/Delete Vehicle To DELETE a vehicle, please provide the following: To ADD a vehicle, please provide the following: Will vehicle be driven locally (50-100 mile radius)? How is this vehicle used? Any permanently installed equipment on vehicle? If yes, please list equipment and value: Desired Coverage (choose one) If not or only vehicle with full coverage, please list desired deductible for comprehensive and collision coverage:
By signing and typing your name below, you are authorizing changes to your policy.
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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.