Vehicle/Driver Change Request Form

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Vehicle/Driver Change Request Form

If you need to add/delete/change more than one vehicle/driver, please complete the attached form. Once completed, please fax or email the form to:(714)546-4457, or via email to: PolicyChange@rsi-ins.com

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Insured*
Name*
First Last
Address*
Street Address City State ZIP Code
Client Code*
Phone*
Fax
Requested By*
Effective*
Action
- Add
- Delete
- Change

Vehicle Information
Year and Make of Vehicle*
Vehicle Type*
Vehicle Serial #*
Vehicle Value*
Additional Insured Info*
(Please include name and address below)
Loss Payee Info*
(Please include name and address below)

Driver Information - Please indicate add/delete below*
- Add
- Delete
Driver Name*
First Last
Driver's License #*
State*
Driver Date of Birth*
Driver Social Security #
Driver's Hire Date*
Driver's # years experience*
If available, do you want any additional premium added to current finance agreement?
Instructions/Information/Comments