General Insurance Agency, Inc.
Vehicle Change Request

Please provide the following contact information (all information is required):

Contact Name
Title
Organization Name
Mailing Address
Address (cont.)
City
State
Zip/Postal Code
Station Phone xxx-xxx-xxxx
Home or Cell Phone xxx-xxx-xxxx
E-mail

Add Vehicle Use this section only to add a vehicle to your policy.
Year
Make
Model (Pumper, Aerial, etc.)
VIN #
Agreed Value
Effective Date mm/dd/yyyy

Delete Vehicle Use this section only to delete a vehicle to your policy.
Year
Make
Model (Pumper, Aerial, etc.)
VIN #
Delete Physical Damage?
Delete Liability?
Effective Date

Note:  Liability coverage should be deleted only after the vehicle is no longer in your physical possession.

Other Changes (Add, delete leinholder, increase/decrease agreed value, etc.)
Explain
By submitting the above information, you are attesting that you are an authorized delegate of the organization to make changes to your policy and the contact information we have on file matches the information you are sending.  Should any discrepancies be noted between our records and your submission, no change will be made until it can be verified.

General Insurance Agency, Inc.
Copyright © 2008 [General Insurance Agency, Inc.]. All rights reserved.
Revised: 11/19/08