Automobile Policy Change Request

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#:
Defensive Driving 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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Important Note: This website provides only a simplified description of coverages and is not a statement of contract. Coverage may not apply in all states. For complete details of coverages, conditions, limits and losses not covered, be sure to read the policy, including all endorsements.

Community Insurance Group

139 Harristown Road, Suite 202
Glen Rock, New Jersey 07452

Phone:
Toll Free:
Fax:
Fax (NJ only):

201-444-4426
855-344-4426
201-444-0731
800-440-2267