CONSUMER POLICY CHANGE REQUEST - Dorsey Properties

1 CONSUMER POLICY CHANGE REQUESTPLEASE PRINT ALL INFORMATIONPOLICYEFFECTIVE DATE OF CHANGEMONTH DATE YEARNUMBERNAMED INSURED - EXACTLY AS ON POLICY1. ADDRESS (IF CHANGE )CITYSTATEZIPC ancel PolicyReason:Signature of Insured:IF PO BOX ADDRESS - ALSO NEED STREET LOCATION:STREETCITYSTATEZIPCOUNTYPHONE #ADD: : : DATE:PURCHASE PRICE:VALUEYEARMAKE,MODEL,BODY TYPE*| | | | | | | | | | | | | | | || | | | | | | | | | | | | | | |VIN # ANNUALMILEAGEUSEHAVE YOUINSPECTEDVEHICLE?**Are all Vehicles listed above titled only to applicant?YesNo Explain "no."*If pickup or new car, please give cost new under Miscellaneous.**If prior damage, please explain under Equipped with: Sound Reproducing Equipment? Optional Equipment? Explain in PAYEE CHANGE :Collision or other than collision PAYEESameAddChangeDeleteLEASING INSUREDA pplicable to: All VehiclesorNAMEMake / Model YearSTREETCITYSTATEZIPCHANGE OF COVERAGEADDDELETEREVISEList Vehicle Make/Model/Year**COMPREHENSIVE**COLLISIO N - TRANS EXPTOWING & LABOR**Limits for coverages below must be the same on all vehicles.

2 ** Not available on vehicles over 10 years INJURYPROPERTY DAMAGEPERSONALINJURYPROTECTION:MEDICALWO RK LOSSACC. DEATHMEDICAL PAYMENTSUNINSURED*MOTORISTSBIPDUNDERINSU RED*MOTORISTSBIPDDEATH &DISABILITYLIMITSNAMES**Non-Standard Only1. If adding physical damage, must have 2 I have inspected the vehicle covered by physical 's Initials*If rejected, need a signed CHANGE OR ADDITION:Social Security #Name/RelationshipBirth DateSexMaritalStatusDriver's License# / State of Issue# YearsLic DriverDelete Driver - ReasonAccidents / Violations / ConvictionsOccupation / EmployerMISCELLANEOUS: CHANGE OF AGENT FROM #TO #AUTHORIZED BYThis REQUEST for a POLICY CHANGE written by Agent:As Agent, I REQUEST that the changes specified above be made on this (2/04)Agent's NameTimeDat