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Auto Policy Change Request
starklogic
2021-06-22T11:08:45+00:00
Auto Policy Change Request
Personal Auto Policy Change
Please fill out the following form to request all auto policy changes. We will process your request upon submission. Thank you.
Agency Name
*
Agent Name (Contact Person)
*
First
Last
Agent Email
*
Agent Phone #
*
Insured's Name
*
First
Last
Policy Number
*
Effective Date of Change
*
MM slash DD slash YYYY
Is there a change in the address?
*
Yes
No Change
Which Address Are You Changing
*
Mailing
Physical
Both
Reason for Address Change?
New Address
*
Street Address
Address Line 2
City
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
State
ZIP Code
Is there a change to the vehicle information?
*
No Change
Add
Delete
Replace
Purpose for deleting vehicle?
Vehicle to be Replaced
*
Year
Make
Model
VIN
Vehicle to be Added
*
Year
Make
Model
VIN
Driver of this Vehicle
Name on Title
Purchase Price
Vehicle to be Deleted
*
Year
Make
Model
VIN
Name on Title
Purchase Price
Purchase Date
*
MM slash DD slash YYYY
Purchased New (Original Owner)
*
Yes
No
Is the vehicle leased
*
Yes
No
Garaging Address
*
Same as other vehicles
Other Address
Other address
*
Anti-Lock Brakes
Yes
No
Air Bags
Yes
No
Anti-Theft Device
Yes
No
Usage
*
Pleasure
Work
Business
Farm
Miles One-Way
*
Annual Mileage
*
Comp Deductible
*
250
500
1,000
None
Collision Deductible
*
250
500
1,000
None
Rental
*
Same as current vehicles
None
Other
Other Rental
*
Towing
*
15
50
75
100
none
Additional Remarks
Is there a change to the Lienholder Information
*
No Change
Add
Delete
Replace
Lienholder to be replaced
*
Lienholder to be added
*
Which vehicle will this lienholder be added to ?
*
Which vehicle will this lienholder be deleted from?
*
Which vehicle will this lienholder be replaced on ?
*
New Lienholder's Address
*
Street Address
Address Line 2
City
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
State
ZIP Code
Loan # with new Lienholder?
Additional Remark
Is there a change to any drivers?
*
No Change
Add
Delete
Name of Driver to Be Added
*
First
Last
Name of Driver to be Deleted
*
First
Last
Drivers License #
*
Issuing State of License
*
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
Date Licensed
*
MM
1
2
3
4
5
6
7
8
9
10
11
12
DD
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
YYYY
2023
2022
2021
2020
2019
2018
2017
2016
2015
2014
2013
2012
2011
2010
2009
2008
2007
2006
2005
2004
2003
2002
2001
2000
1999
1998
1997
1996
1995
1994
1993
1992
1991
1990
1989
1988
1987
1986
1985
1984
1983
1982
1981
1980
1979
1978
1977
1976
1975
1974
1973
1972
1971
1970
1969
1968
1967
1966
1965
1964
1963
1962
1961
1960
1959
1958
1957
1956
1955
1954
1953
1952
1951
1950
1949
1948
1947
1946
1945
1944
1943
1942
1941
1940
1939
1938
1937
1936
1935
1934
1933
1932
1931
1930
1929
1928
1927
1926
1925
1924
1923
1922
1921
1920
Gender
*
Male
Female
Date of Birth
*
MM
1
2
3
4
5
6
7
8
9
10
11
12
DD
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
YYYY
2023
2022
2021
2020
2019
2018
2017
2016
2015
2014
2013
2012
2011
2010
2009
2008
2007
2006
2005
2004
2003
2002
2001
2000
1999
1998
1997
1996
1995
1994
1993
1992
1991
1990
1989
1988
1987
1986
1985
1984
1983
1982
1981
1980
1979
1978
1977
1976
1975
1974
1973
1972
1971
1970
1969
1968
1967
1966
1965
1964
1963
1962
1961
1960
1959
1958
1957
1956
1955
1954
1953
1952
1951
1950
1949
1948
1947
1946
1945
1944
1943
1942
1941
1940
1939
1938
1937
1936
1935
1934
1933
1932
1931
1930
1929
1928
1927
1926
1925
1924
1923
1922
1921
1920
Marital Status
*
Single
Married
Divorced
Separated
Widowed
Relationship to Primary Insured
*
Child
Spouse
Domestic Partner
Parent
Relative
Other
Relationship
*
Primary Vehicle of this Driver
*
Driver Credits Documents
Defensive driver, good student, drivers training documentation can either be attached here or must be faxed to SLS (918-336-2178) in order for the discounts to apply.
Drop files here or
Select files
Max. file size: 32 MB.
Reason driver is being deleted.
*
Additional Comments
File Upload
Max. file size: 32 MB.
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