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Request a Change

  1. Request a Change
Request a ChangeVictor Gonzalez2023-07-27T19:45:26-04:00

"*" indicates required fields

Please note. Any change requests made on this page is just a request for service and does not alter the policy until a formal confirmation and endorsement is received and remitted from the insurance carrier.
MM slash DD slash YYYY
Name*

Drivers

Drivers Checkboxes
Check all that apply

Add Driver

New Driver: Name*
New Driver: Date of Birth*
If you need to send us a copy of the driver's MVR, drivers license, or other related file, please add them here.
Drop files here or
Accepted file types: jpg, gif, png, pdf, jpeg, Max. file size: 12 MB, Max. files: 10.

    Update Driver

    Update Driver: Name*
    Please tell us what we should update regarding this driver.
    If you need to attach any files related to this request, please add them here.
    Drop files here or
    Accepted file types: jpg, gif, png, pdf, jpeg, Max. file size: 12 MB, Max. files: 10.

      Delete Driver

      Delete Driver: Name*
      If you need to attach any files related to this request, please add them here.
      Drop files here or
      Accepted file types: jpg, gif, png, pdf, jpeg, Max. file size: 12 MB, Max. files: 10.

        Vehicles

        Vehicle Checkboxes
        Check all that apply

        Add / Replace a Vehicle

        Replace a Vehicle
        If you need to attach any files related to this request, please add them here. Examples include copy of title, bill of sale, picture(s) of VIN, copy of drivers license, current policy documents, etc.
        Drop files here or
        Accepted file types: jpg, gif, png, pdf, jpeg, Max. file size: 12 MB, Max. files: 10.

          Delete Vehicle

          If you need to attach any files related to this request, please add them here. Examples include copy of title, bill of sale, picture(s) of VIN, copy of drivers license, current policy documents, etc.
          Drop files here or
          Accepted file types: jpg, gif, png, pdf, jpeg, Max. file size: 12 MB, Max. files: 10.

            Addresses

            Address Change Type
            Check all that apply
            New Mailing Address
            New Physical Address
            New Garaging Address
            If you need to attach any files related to this request, please add them here.
            Drop files here or
            Accepted file types: jpg, gif, png, pdf, jpeg, Max. file size: 12 MB, Max. files: 10.
              Add Lien Holder To My

              Add Lien Holder to Property

              Lien Holder Address*
              Optionally, upload any documents from your lender that may assist us in making this change.
              Drop files here or
              Accepted file types: pdf, jpg, png, jpeg, docx, Max. file size: 12 MB, Max. files: 5.

                Add Lien Holder to Vehicle

                Optionally, upload any documents from your lender that may assist us in making this change.
                Drop files here or
                Accepted file types: pdf, jpg, png, jpeg, docx, Max. file size: 12 MB, Max. files: 5.

                  Certificate of Insurance

                  Address of company to be listed on certificate*
                  Optionally, add the insurance requirements or other files we may need related to this certificate request.
                  Drop files here or
                  Accepted file types: pdf, jpg, png, doc, docx, Max. file size: 12 MB, Max. files: 5.

                    Coverage Change

                    General Request

                    Optionally add any files we may need to process this change request.
                    Drop files here or
                    Accepted file types: jpg, png, gif, pdf, Max. file size: 12 MB, Max. files: 5.

                      Request Summary

                      Below, is the summary of change(s) you are requesting.
                      If anything is not correct, please go back and make any updates prior to submitting your change request.

                      Request Date: {Date to make this change:4}

                      Change Type: {Change Type:7}

                      Add Driver

                      Name: {Name (First):13.3} {Name (Last):13.6}
                      Date of Birth: {Date of Birth:16}
                      Gender: {Gender:15}
                      Drivers License: {Drivers License Number:19} / {Driver License State:20}

                      Update Driver

                      Name: {Name (First):26.3} {Name (Last):26.6}
                      Update Request:
                      {Update Request:27}

                      Delete Driver

                      Name: {Name of Driver (First):30.3} {Name of Driver (Last):30.6}
                      Reason for Deletion:
                      {Reason for Deletion:31}

                      Add / Replace Vehicle

                      Vehicle to Add: {Year:37} {Make:38} {Model:39}
                      VIN: {VIN:40}
                      Primary Use: {Vehicle Primary Use:41}
                      Vehicle to Replace: {Year, make, and model of vehicle you would like to replace:45}

                      Delete a Vehicle

                      Vehicle to Delete: {Year, make, and model of vehicle to delete:48}
                      Reason for Deletion: {Reason for Deletion:49}

                      Change of Mailing Address

                      {New Mailing Address (Street Address):54.1} {New Mailing Address (Address Line 2):54.2}
                      {New Mailing Address (City):54.3}, {New Mailing Address (State / Province):54.4} {New Mailing Address (ZIP / Postal Code):54.5}
                      {New Mailing Address (Country):54.6}

                      Change of Physical Address

                      {New Physical Address (Street Address):55.1} {New Physical Address (Address Line 2):55.2}
                      {New Physical Address (City):55.3}, {New Physical Address (State / Province):55.4} {New Physical Address (ZIP / Postal Code):55.5}

                      Change of Garaging Address

                      {New Garaging Address (Street Address):56.1} {New Garaging Address (Address Line 2):56.2}
                      {New Garagin Address (City):56.3}, {New Garaging Address (State / Province):56.4} {New Garaging Address (ZIP / Postal Code):56.5}

                      Property Lien Holder

                      Lien Holder Name: {Lien Holder Name:62} {Lien Holder Name (Line 2):63}
                      Lien Holder Address:
                      {Lien Holder Address (Street Address):64.1} {Lien Holder Address (Address Line 2):64.2}
                      {Lien Holder Address (City):64.3}, {Lien Holder Address (State / Province):64.4} {Lien Holder Address (ZIP / Postal Code):64.5}
                      Loan Number: {Loan Number:65}
                      Bill to: {Bill To:68}

                      Vehicle Lien Holder

                      Vehicle to add lien holder to: {Vehicle to add this lien holder to:69}
                      Lien Holder Name: {Lien Holder Name:89}
                      Loan Number: {Loan Number:90}

                      Certificate of Insurance Request

                      Company Name: {Name of company to be listed on COI:72}
                      Company Address:
                      {Address of company to be listed on COI (Street Address):92.1} {Address of company to be listed on COI (Address Line 2):92.2}
                      {Address of company to be listed on COI (City):92.3}, {Address of company to be listed on COI (State / Province):92.4} {Address of company to be listed on COI (ZIP / Postal Code):92.5}
                      Request Details: {Request Details:78}
                      COI Related Document(s):
                      {Certificate Request Documents:74}

                      Coverage Change

                      General Request

                      Request Details:
                      {Request Details:78}
                      Files:
                      {File Upload:79}
                      Policy Change Agreement*
                      I agree and understand this request does not change the policy coverages or hold the request effective on the policy. The insurance carrier will send me a written confirmation that the request can be made in the form of an endorsement that the request can be made or that the request has been processed. I also, understand this request may increase or decrease the overall premium, and if it does, I will be notified in writing before the change is processed. Until I receive written confirmation that coverage is afforded I understand coverage is not altered or bound by this request.
                      This field is for validation purposes and should be left unchanged.

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                      Miami, Florida Office

                      16155 SW 117 Ave., #B17
                      Miami, Florida 33177
                      Phone: 866-500-2175

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                      7777 Davie Road Extension #200B
                      Hollywood, Florida 33024
                      Phone: 954-475-8886

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                      603 E. Fort King Street
                      Ocala, Florida 34471
                      Phone: 352-545-3025

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