Customer Forms - Auto Change Request
By entering the requested information we will be able to process and return your auto change request. If you should have any questions regarding the completion of the form you may call us at (937) 339-4119 or email kmartin@kovermandickerson.com. Your request will be submitted and processed within 2 business days. You will be notified when the request has been completed.
General Information
Your Name:
Phone Number:
Email Address:
Best way / Time to Contact:

Vehicle Information
Add or Delete:
Effective Date:
Make:
Model:
Year:
*VIN:
  (*Vehicle Identification Number)
Check items that apply


Purchase/Lease Information
Purchased or Leased:
Loan or Lease Company:
Address:
 
City:
State:
Zip:
Is GAP coverage desired:

Driver Information
Primary Driver Name:
Vehicle Usage
Miles to Work (One Way)
Is this a new driver on this policy:

(If yes, please provide the following:)
Date of Birth:
Social Security Number
Drivers License Number:
State
*Does Good Student Discount Apply:
  (*Requires B Average or Better)
Comments:
Please enter the characters from the image below. (Case sensitive)