Palmer & AssociatesPalmer & Associates
78 Eastern Blvd
PO Box 536
Glastonbury, Connecticut 06033
Phone: (860) 633-3567
Toll Free: (888) RPALMER

Request to Replace Vehicle on Auto Policy

Requestor Information

First Name:*

Last Name:*

Email Address:*

Phone:*

We will confirm the policy change by email. If you prefer a FAX, please provide a FAX number.

Policy Holder Information (if different than requestor)

Policy Number (required if you have more than 1 auto policy)

First Name:

Last Name:

Change Information (Delete Vehicle - Add Vehicle)

Date Change is to be Effective:*

Replaced Vehicle Year:*

Replaced Vehicle Make:*

Replaced Vehicle Model:*

Replaced Vehicle VIN (Serial Number) - required if you have 2 identical vehicles insured:

New Vehicle (Replacing) Year:*

New Vehicle Make:*

New Vehicle Model:*

New Vehicle VIN (Serial Number)*

Deductible:*

Driver Changes

Will the same driver be assigned to the new vehicle?*

Yes No

If a new driver will be the primary driver for the new vehicle, please provide drivers name.

Lienholder/Finance/Vehicle Information

Is the vehicle financed or leased?*

Not Financed or Leased Financed Leased

Name of owner(s) on the vehicle title:

Complete the following If the vehicle is financed or leased.

Leasing or Financing Company Name:

Address 1:

Address 2:

City:

State:

Zip Code:

Finance or Lease Term:

Amount Financed:

Questions or Comments

Binding Agreement

(Required) I understand that any policy changes and quote requests are effective only when I have received a written confirmation.*

I agree

*Required fields:

This submission is a request. Insurance coverage changes and new coverages are not effective until we confirm that for you.

We will do our best to complete this request based on the information you provide. The more complete your information, the more accurate your quote will be.

Security:
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