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


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(* means required)

 

* Your Business Name

   

* Your Name

* Phone Number

* 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?


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