Policy Services | Willard Insurance Agency

Personal Auto

General automobile policy change

Name on policy*

First

Last

Your email address*

Your phone number

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

Please describe in detail the changes you need us to make to your policy.

Date for auto policy change to be effective*

Some policy changes can create gaps in coverage or involve other risks. Some common coverage limitations are listed below. Would you like someone from Willard Insurance Agency to contact you to review aspects of your insurance policy with you?

Yes

Please check any area where you think there may be a gap in protection

Business use of personal autos

Complete coverage check up

Custom equipment

Enhanced Liability Protection

Review discount eligibility

Other

Questions or comments

I understand that any policy changes are effective only when I have received a written confirmation. This submission is a request. Insurance coverage changes and new coverage are not effective until we confirm that with you. We do our best to complete this request based on the information that you provide. The more complete your information is, the more accurately we can assist you. *

I agree

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Auto insurance ID card request

Your name

First

Last

Your Email address*

Your phone number*

How should we contact you if we have any questions?*

Phone

How should we send the ID cards to you?

Mail (Will be sent to the address on your policy record)

Policy Holders Name

First

Last

Policy Number (if known)

Vehicle 1 Year

Vehicle 1 Make

Vehicle 1 Model

Vehicle 2 Year

Vehicle 2 Make

Vehicle 2 Model

Vehicle 3 Year

Vehicle 3 Make

Vehicle 3 Model

Questions or Comments

We do our best to complete this request based on the information that you provide. The more complete your information is, the more accurately we can assist you.

I understand*

I understand

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Request to add a driver to my auto policy

Your name*

First

Last

Your email address*

Your phone number

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

Name on policy

First

Last

Policy Number

New drivers name

First

Last

Relationship to policy holder

Date of birth of new driver

Drivers license number of new driver

Drivers license state

Status of new driver

Full time driver

Part time driver

Date to add driver

Vehicle Assignment Information

Year of vehicle

Make of vehicle

Model of vehicle

Vehicle VIN

Comments or questions

I agree

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Request to add a lienholder to my auto policy

Requestor Information

Name

First

Last

Email address*

Phone

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

Policy Holder Information

Policy holder name*

First

Last

Policy number

Lienholder Information

Lienholder name*

Lienholder address

Street Address Street Address Line 2 City State / Province / Region Postal / Zip Code

Date for lienholder to be added*

Term of lease of financing

Amount of financing

Vehicle Information (for new lien)

Vehicle year

Vehicle make

Vehicle model

Vehicle VIN

Questions or comments

I agree

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Request to add a vehicle to my auto policy

Requestor Information

Your name

First

Last

Your email address*

Your phone number

Preferred method of contact

Phone

Policy Information

Policy holders name

First

Last

Address of policy holder

Street Address Street Address Line 2 City State / Province / Region Postal / Zip Code

Policy number

Effective date to be added*

Comprehensive deductible

Collision deductible

Vehicle Information

Name of owner(s) on the vehicle title

Vehicle VIN

Vehicle year

Vehicle make

Vehicle model

Is the vehicle leased or financed?

Yes

Lienholder name

Lienholder address

Street Address Street Address Line 2 City State / Province / Region Postal / Zip Code

Amount financed

Finance or lease term

Primary Driver Information

Primary driver of new vehicle

First

Last

New driver date of birth

day

month

year

New driver years driving experience

New drivers drivers license number

New drivers license issuing state

Questions or comments

I agree

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Request to delete a vehicle from my auto policy

Requestor Information

Requestor name

First

Last

Requestor email*

Requestor phone number

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

Policy holder information

Name

First

Last

Policy number

Change information

Date the change is to be effective*

Vehicle year

Vehicle make

Vehicle model

VIN

Driver Reassignment

Will the primary driver of this vehicle now be the primary driver of another vehicle? If so, please provide vehicle information

Yes

New vehicle assignment year

New vehicle assignment make

New vehicle assignment model

New vehicle assignment VIN

Questions or comments

I agree

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Request to replace a vehicle on my auto policy

Policy holder name

First

Last

Policy number

Your email

Phone number

We will confirm any changes by email. If you prefer a fax, please provide a fax number.

Date the change is to be effective

Replaced vehicle year

Replaced vehicle make

Replaced vehicle model

Replaced vehicle VIN

New vehicle year

New vehicle make

New vehicle model

New vehicle VIN

Deductible

Will the same driver be assigned to the new vehicle?

Yes

New driver

First

Last

Name of owner(s) on the vehicle title

Is the vehicle leased or financed?

Not financed or leased

Leased

Financed

Leasing or fianancing company

Leasing or financing companies address

Street Address Street Address Line 2 City State / Province / Region Postal / Zip Code

Lease or finance terms

Amount financed

Questions or comments

I agree

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Homeowners Insurance

General homeowners policy change

Policy holder name

First

Last

Your email*

Your phone number

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

Home location

Street Address Street Address Line 2 City State / Province / Region Postal / Zip Code

Please describe the change you need us to make.

Date the change needs to be effective*

Some policy changes can create gaps in coverage or other risks. Some common coverage limitations are listed below. Would you like us to contact you to review aspects of your homeowners insurance with you?

Yes

Please check any areas where you feel there may be a protection gap

Complete homeowners insurance review

Earthquake

Enhanced Liability Protection

Flooding

Home business / office

Insuring important / valuable items

Review discount eligibility

Other

Questions or comments

I agree

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Business Insurance

Business insurance policy change request

Name of business as shown on policy

Business address

Street Address Street Address Line 2 City State / Province / Region Postal / Zip Code

Policy number

Your name

First

Last

Your email address*

Your phone number

Fax number

Policy change request

Type of policy

Description of change requested

Date for change to be effective

Other coverage and risk considerations

Some policy changes can create gaps in coverage or other risks. Some common coverage limitations are listed. Would you like us to contact you to review aspects of your business insurance policy with you?

Yes

Check any areas where you feel that there may be a protection gap

Bonds

Business Automobile

Business Interruption

Commercial Liability

Commercial Property

Crime

Cyber Liability

Directors & Officers

Disability

Employment Practices Liability

Errors and Ommissions

Umbrella

Worker’s Compensation

Other

Questions or comments

I agree

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Certificate of insurance request

Requestor Information

Company name*

Your name*

First

Last

Your email address*

Your phone number

Your fax number

What is your relationship to the name insured?*

Insured Information

What is the name of insured? (Name shown on the policy)

Certificate Holder Information

Certificate holder name

Certificate holder Email address

Certificate holder address

Street Address Street Address Line 2 City State / Province / Region Postal / Zip Code

Certificate holder phone number

Certificate holder fax number

How should we send the certificate to the holder?

Fax

Attention of:

Type of coverage

General Liability

Auto Liability

Workers’ Compensation

Umbrella Liability

Other

If “other”, please list

Additional Insured

Is the certificate holder requesting additional insured status?

Yes

Is there an executed written contract requiring an additional insured?

Yes

Additional insured

Additional insured address

Street Address Street Address Line 2 City State / Province / Region Postal / Zip Code

For which lines would the certificate holder be named as additional insured?

General Liability – With products/Completed operations

General Liability – Without products / Completed operations

Commercial Auto

Product Liability

Umbrella

Special Instructions

Start date of job

When do you need the certificate by?

Please list any instructions or requirements

Please list the contract or job number if you need it on the certificate

Waiver of subrogation requested

Waiver for commercial automobile

Waiver for general liability

Waiver for workers’ compensation

State(s) where work will be performed

Payroll for this job

Upload a File

I agree

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Policy Services | Willard Insurance Agency

Insurance Policy Services

Personal Auto

Homeowners Insurance

Business Insurance

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Willard Insurance Newsletter

IMPORTANT LINKS

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Policy Services | Willard Insurance Agency

Insurance Policy Services

Personal Auto

Homeowners Insurance

Business Insurance

Subscribe to the Willard Insurance Newsletter

IMPORTANT LINKS

QUICK CONTACT

Subscribe to the
Willard Insurance Newsletter