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 disclaimer.   (Box must be checked before request can be sent)

Select Account Representative Please select your account representative, or leave as "General Representative" if you do not have one: General Representative Carol McIsaac Donna Foster Judith Graham Kathy East Margaret Rosa Teresa Heupel Toni Peconi Valerie King

Policy Holder Information Name Insured: Phone #:     E-Mail: Effective Date of Change:

IF ADDING a vehicle: Year:     Make Model:     Serial #: Cost: $ Anti-Lock Brakes: 0     1     2 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

IF ADDING a driver: Name: Relationship:     DL#: Date of Birth:     SS#: Defensive Driving Certificate? Yes     No Drivers Training Certificate? Yes     No

IF DELETING a vehicle: Effective Date of Change: Year:     Make: Model:     Serial #:

IF DELETING a driver: Name: Reason: