___________________________________________

Contact Name (required)

Company Name (required)

Date of Change (required)

Date of Purchase/Lease (required)

Please add the following unit:

Year

Make

Model

Body Style

VIN#

Weight
---GVWGCW

Titled to

Garaged at

Purchased/Leased from

Address

New List Price

Coverage/Liability Only
---yesno

Full Coverage
---yesno

Use (hold shift to make multiple selections)
---businesspersonal

On file
---yesno

Deductibles:

Comprehensive

Collision

New Driver
---yesno

Driver's Name

Date of Birth

State

___________________________________________

Please delete the following unit:

Year

Make

Model

Last 3 of VIN#

___________________________________________

Comments (Please explain tickets or accidents here):

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Coverage cannot be bound or changed via fax, e-mail or CIG website.
CIG staff will contact you for verification and/or additional questions regarding your request.