" The insurance companies that we represent must be client conscious and financially strong. Many of these companies offer multiple policy credits and a loss free discount."


Independent Insurance Agent
H&K Automobile Change Request Form

Please use the form below to notify us of any changes to your automobile policy insured through this company/agency. Please note that this form is for notification purposes and any changes will not be binding until you receive confirmation from our company/agency.

Disclaimer
I understand that my coverage (or changes in coverage) ARE NOT binding via this on-line request; Changes ARE considered binding when I receive an email (or fax) response from my agent indicating that they have received my request.

I have read and agree with the above disclaimer.
(Box must be checked before request can be sent)

Policy Holder Information
Name Insured:
Phone #: E-Mail:
Effective Date
of Change:

IF ADDING a vehicle:
Year: Make
Model: Serial #:
Cost: $
Anti-Lock Brakes: 0 1 2
Air Bags: None Driver Driver/Passenger
Anti-Theft Device: Yes No
How will car
be driven?
(Check One):		 Farm To/From Work In Business
Car Pool Pleasure

IF ADDING a driver:
Name:
Relationship: DL#:
Date of Birth: SS#:
DefensiveDriving
Certificate?		 Yes No
Drivers Training
Certificate?		 Yes No

IF DELETING a vehicle:
Effective Date
of Change:
Year: Make:
Model: Serial #:

IF DELETING a driver:
Name:
Reason:



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