I, ________________________________request change/s as indicated to be made to my policy.
Print Name

Effective Date of Change/s: ______________________ Policy Number: __________________

Change/Add/Delete Vehicle
To change or add a vehicle you must provide one of the following. The pink slip (signed by both parties), sales contract (from auto dealer), bill of sale (signed by both parties), or registration (in your name) for the vehicle you are adding. Without one of these the change/s cannot be made.

Change Vehicle: You must complete both "Add and Delete Vehicle" sections to change vehicle/s.

• Add Vehicle: Year/Make/Model _________________________________________
  Specify below what limits of coverage to add (Circle Add/Increase) when adding a
  vehicle.
• Delete Vehicle: Year/Make/Model _________________________________________

Change/Add/Delete Coverages
To change coverages on your policy, circle either Add/Increase or Delete/Reduce, and then fill in the blanks.

Circle One Add/Increase Delete/Reduce

• Limits of Liability: ________________________.
• Limits of Uninsured Motorist Bodily Injury and Property Damage: ____________.
• Comprehensive and Collision with $___________ deductible.
  Changes in comprehensive and collision will require an in-office vehicle inspection.
• Excess medical coverage in the amount of $_____________.

Please read and sign below:
It is understood and agreed that the requested change/s are not valid unless submitted in writing (signed by the named insured) with all necessary documentation and appropriate premium and/or fees paid. Any change/s to a policy can result in increased premium and/or fees charged by the insurance company (especially "Add or Add/Increase" change/s). The Broker may also charge a fee (disclosed on the Broker/Customer Agreement). It is the Customer's responsibility to be aware of and submit correct documentation along with sufficient funds to facilitate changes requested of the Broker. Customer agrees they are responsible for all fees and premiums and if not submitted at the time of this change request the Broker and/or the insurance company will bill them for such. All changes must be acknowledged and accepted in writing by your insurance company. Change/s requested to a policy in lapse or cancel status will not be made. Customer understands that insurance company processing of change request/s may take up to 6 weeks. Customer must pay any bill/invoice they receive from the insurance company, regardless if the change requested herein is reflected in the bill/invoice. All fees are fully earned for services rendered regardless of policy status and/or acceptance of change/s. Processing of change request form/s by Big Dan's Insurance Agency does not insure that coverage is now or has ever been in force.

_______________________________________________________/___________________
Customer's Signature/Date
Changes will not be processed without signature.