Morton Insurance & Risk Management

Automobile Policy Change Request

Policy Holder Information
Name Insured:
Address:
City:
State:	Zip:
Phone #:	E-Mail:
Effective Date of Change:
Insurance Company
Policy Number

IF ADDING a vehicle:

Year: Make

Model: VIN #:

Cost: $

Anti-Lock Brakes:

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:

Effective Date
of Change:

Year: Make:

Model: VIN #:

IF DELETING a driver:

Name:

Reason: