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and speak with
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A.J.Benet Home Page > Client Services > Automobile Policy Change Request

AUTOMOBILE

POLICY CHANGE
REQUEST

  

Please use the form below to notify us of any changes to your automobile policy insured through this company/agency. Please note that this form is for notification purposes and any changes will not be binding until you receive confirmation from our company/agency.
 

Disclaimer

I understand that my coverage (or changes in coverage) ARE NOT binding via this on-line request; Changes ARE considered binding when I receive an email (or fax) response from my agent indicating that they have received my request.

 I have read and agree with the above disclaimer.

  (Box must be checked before request can be sent)

PLEASE NOTE: For a NEW CAR, send or fax ((914)381-5089) us a copy of the Bill of Sale and Window Sticker. If a leased vehicle, send or fax us a copy of the Lease Agreement.

Policyholder Information

Name Insured:

Phone #:

    E-Mail:

Effective Date
of Change:

IF ADDING a vehicle:

Vehicle is:

        Leased
        Owned

If Leased:
Lessor's Name:
Address/City/State/Zip:
Phone #:     Lease #:

If Purchased and Financed:
Name of Loss Payee:
Address/City/State/Zip:
Phone #:     Loan #:

Year:

    Make

Model:

    Serial #:

Cost:

$

Anti-Lock Brakes:

0     1     2

Air Bags:

None     Driver     Driver/Passenger

Anti-Theft Device:

Yes     No

How will car be driven? (Check One):

Farm     To/From Work     In Business
Car Pool     Pleasure

IF ADDING a driver:

Name:

Relationship:

    DL#:

Date of Birth:

    SS#:

Defensive Driving
Certificate?

Yes     No

Drivers Training
Certificate?

Yes     No

IF DELETING a vehicle:

For New York plates, they must be returned to the DMV and you must obtain and fax ((914)381-5089) to our office FS-6 (proof of surrender of plates) before a vehicle can be deleted.

Effective Date
of Change:

Year:

    Make:

Model:

    Serial #:

IF DELETING a driver:

Name:

Reason:

PLEASE NOTE: For a NEW CAR, send or fax ((914)381-5089) us a copy of the Bill of Sale and Window Sticker. If a leased vehicle, send or fax us a copy of the Lease Agreement.

   

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This Auto Change Request Form Copyright © 2000 - by ENHANCED Web Services

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A. J. Benet, Inc. • 430 Center Avenue • Mamaroneck, NY 10543 • Customer Service: 914-381-2040 • Sales: 914-381-0177 • Fax: 914-381-5089

Important Note: This website provides only a simplified description of coverages and is not a statement of contract. Coverage may not apply in all states.
For complete details of coverages, conditions, limits and losses not covered, be sure to read the policy, including all endorsements.

©2012 A.J. Benet, Inc. Insurance