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)46-4457, 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* *

Driver Information -please indicate add/delete below *

Add Driver
Delete Driver

Driver Name *

Driver's License #, and State *

Driver's Date of Birth (month/day/year) *

Driver's Social Security#

Driver's Hire Date
(month/day/year) *

Driver's Years of Experience *

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

Instructions/Information/Comments