HAUSMANN-JOHNSON INSURANCE DesignlynxSM

  VEHICLE CHANGE FORM

 

This form is for Commercial Vehicle changes ONLY

Please contact your Personal Lines representative for private or individual auto changes.
Today's Date: Named Insured
For Assistance: Insured Phone No: 

Phone:  (608) 257-3795  or 1(800) 729-4287

From: 

Fax:       (608) 257-4324

Insured Email:
   
  ADD VEHICLE:
Title Owner:
Effective Date: Your Fleet Number: 
Year: Make: Model:
Vehicle ID # 
Gross Vehicle Weight   Purchase Price
Vehicle Use:  Garage Location:
    Owned   or   Leased   Lienholder Name
  Loss Payee     Addl Ins. Address 
Is Lienholder also an additional insured? Yes
No		 Radius of Use (Miles)
Coverages:
Liability  Comprehensive     Collision
Y   N      Y   N    Y  N  
  DELETE VEHICLE
Date of Title Transfer 
Year  Make 
Model  Vehicle ID #
Reason
  		Sold      Inactive or Leased & Turned In  
Trade-In  

        Copyright 2008 © Hausmann-Johnson Insurance, Inc. All rights reserved.