Auto Policy Change Request

Definition: Delete, Replace, or Change Coverage on a Vehicle.

» Required Fields


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 (Box must be checked before request can be sent)

Policy Holder Information:
» Name Insured:
» Phone Number:
» Email:
Policy Number:
» Effective Date of Change:

If Adding a Vehicle:
Year:
Make:
Model:
Cost:
Anti-Lock Brakes:	Yes No
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
Miles One Way to Work:
Primary Driver:
Relationship to Insured:
Age:
Defensive Driving Certificate?	Yes No
Drivers Training Certificate?	Yes No
Comp Coverage?	Yes No
Coll Coverage?	Yes No
Towing?	Yes No
Rental?	Yes No

If Deleting a Vehicle:
Effective Date of Change:
Year:
Make:
Model:

If Deleting a Driver:
Name:
Reason:

Benton Insurance Center, Inc.

P.O. Box 300;

16334 Dunnings Hwy.

Newry, PA 16665

Phone: 814-695-4413

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Fax: 814-695-0603

www.bentonins.com

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