If you are not one of the currently approved contacts for your organization,
we will not begin processing this request until confirmed.

*Insured

*Address

City State Zip Code *Phone

Business Auto Policy #

Change requested by:

E-mail

(* Fields are required)

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Vehicle Information

	Add or Delete?	Change Effective Date	Year	Make	Model	Seating Capacity
1	Add Delete	/ /
2	Add Delete	/ /
3	Add Delete	/ /
4	Add Delete	/ /

 

	Vehicle ID #	Liability Only (Veh 15 yrs+)	Cost New	Garage City, State & Zip
1		Yes No
2		Yes No
3		Yes No
4		Yes No

Physical Damage Coverage: Indicate preferred Comprehensive/Collision deductibles – Not available on vehicles 15 yrs+

	Comprehensive Choose one - OR	Other	Collision Choose one - OR	Other
1	100 250 500		100 250 500
2	100 250 500		100 250 500
3	100 250 500		100 250 500
4	100 250 500		100 250 500

Additional Interest: (Please include Full Name and Address)

Vehicle # Loan/Lease Information Is this vehicle leased? Yes No Vehicle # Loan/Lease Information Is this vehicle leased? Yes No

Vehicle # Loan/Lease Information Is this vehicle leased? Yes No Vehicle # Loan/Lease Information Is this vehicle leased? Yes No

Driver Information: Do you need to add a new driver? Yes No

Comments/Additional Information:

Thank you for allowing Church Asset Management to service your insurance needs.