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Community Insurance Group
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Community Insurance Group

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Community Insurance Group

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.

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:
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:


Online Forms by ENHANCED Web Services
This Auto Change Request Form Copyright © 2000 - by ENHANCED Web Services

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Community Insurance Group
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
Community Insurance Group
139 Harristown Road, Suite 202
Glen Rock, New Jersey 07452
Community Insurance Group
Toll Free: 
Fax (NJ only): 
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