Add or Delete A Vehicle

Insured's Name

Policy Number:
Effective Date of Change:
Add Vehicle:

  Year

Make Model
Identification Number 

 Cost New

If Private passenger; Driven to Work or School: Under 15 Miles Over 15 Miles Pleasure
If Truck Indicate Gross Vehicle Weight and Use: GVW Use
Radius of Operation:
When Adding a Vehicle, Indicate who is the Loss Payee and Address. If an Additional Driver Please Specify.
Certificate Holder: Additional Insured Loss Payee

Holder's Name, Address & Loan Number if Required:

Name
Street or P.O. Box
City
State
Zip
Phone
Fax Number
E-Mail

Driver's Name:

D.O.B.

State Licensed

Drivers License #

Delete Vehicle: Year

Make

  Model
Identification Number Cost New
Delete Vehicle: Year Make
 		  Model
Identification Number Cost New

Comments:

Requested By: Date
E-Mail:

No Coverage may be added, changed, or bound as a result of submitting this request. All coverage must be confirmed by Miller & Associates in writing, either via email or fax. If you do not receive a response from us within three working days, please call or email to confirm receipt of request.
I have read and agree with the above disclaimer (It is mandatory to check box before request can be sent)

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