Auto Liability Coverage Change Change Auto Liability Coverage Housing Authority or Insured Entity* Your name* First Last Your email* Your phone*Vehicle DescriptionVehicle make* Vehicle model* Vehicle year* Vehicle color* Vehicle Identification Number (VIN)* Inventory # Are you adding or deleting this vehicle from coverage?* Add Vehicle Delete Vehicle Effective Date* MM slash DD slash YYYY Is this a passenger van?* YES NO If ADDING to coverage, add LIABILITY and/or PHYSICAL DAMAGE?*If not adding either, skip question. ADD Liability Coverage ADD Physical Damage Coverage Add medical coverage (non-employee passengers)?*Medical coverage should be selected if a non-employee(s) is being transported in the vehicle who would not be covered under your Worker's Comp policy in the event of an injury; additional premium applies. YES, add medical coverage NO, do not add medical coverage Add personal use coverage?*Personal coverage should be selected if the vehicle is being used freely for both personal and business use at any/all hours at the discretion of the employee (typically reserved for executive directors); additional premium applies. YES, add personal use coverage NO, do not add personal use coverage Vehicle Purchase Price*ELECTRONIC SIGNATURE* I certify that the information on the application is true and accurate to the best of my knowledge. I understand that if alternate information becomes available, it may result in a change of premium or policy/coverage cancellation. By submitting I am providing my electronic signature. CommentsThis field is for validation purposes and should be left unchanged. Have questions, or need help right away? (360) 574-9035 x107 Rachel O’Neil can answer your questions related to Auto Proof of Coverage requests