Automobile Policy Change Request

Please use the form below to notify us of any changes to your automobile policy insured through this company/agency. Please note that this form is for notification purposes and any changes will not be binding until you receive confirmation from our agency.

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 Tompkins Insurance Agencies indicating that the changes have been made.

 I have read and agree with the above disclaimer.
             (Box must be checked before request can be sent)

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

If adding a vehicle:
Year:     Make
Model:     VIN:
Cost: $
Anti-Lock Brakes: Yes     No    
Air Bags: Yes     No    
Anti-Theft Device: Yes     No
How will car be driven?
(Check One):
Farm To/From Work In Business
Car Pool Pleasure  
Please complete this section if Vehicle is leased or financed
Is this vehicle leased or financed?: Leased     Financed     Neither
Leinholder/Lessor Name:
Leinholder/Lessor Address:
City/State/Zip:    
Amount Leased/Financed: $     Term: (months)
Lease/Finance Start Date:

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:

    VIN#:

If deleting a driver:
Name:
Reason:

 

   

                                                                                                                                                             revised 07.31.08 BH