Automotive Liability Coverage Change

Auto Liability Coverage Change

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This field is for validation purposes and should be left unchanged.
Housing Authority or Insured Entity*
Your name*
First Last
Your email*
Your phone*
Vehicle Description
Vehicle 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*
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
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.

(360) 574-9384

(360)718-5699