Automobile Change Request


(changes will be effective upon confirmation by a King & Neel representative)


Please use your TAB key to move through the form...

(* means required)

 

  * Your Business Name

 
* Your Name 
     * Phone 
 * Email Address 
 Fax Number

 * Effective Date of the Change

 

 

Bought a Vehicle
Got rid of a vehicle
Change to an existing vehicle
Other (specify below) 

 

 

Description of the vehicle to change:

* Model Year 

   * Make/Model

Island where garaged?

 * Serial Number 
Original Cost New 

   Need ID Card?  YES  NO
If a truck, indicate Gross Vehicle Weight:   

Physical Damage Coverage desired?  YES  NO

  

If Yes: Comp Deductible

 If Other, please (specify)

If Yes: Collision  Deductible

 If Other, please (specify)

    

Description of any parties with Additional Interests:

Is the vehicle financed?  YES  NO Is the vehicle leased?  YES  NO

If yes, full name and address of the Loss Payee:
(a certificate of insurance will be issued)


If yes, full name and address of the Lessor:
(a certificate of insurance will be issued)

OTHER COMMENTS OR REMARKS?

If you would like a copy, please PRINT before hitting "submit".  Thank you!