Vehicle 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

Insured *

Name *

Street *

City/State/Zip *

Client Code *

Fax *

Phone *

Requested By *

Effective *

Action

Add
Delete
Change

Vehicle Information

Year & 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* *

If available , do you want any additional premium added to a current finance agreement?

Instructions/Information/Comments