Commercial Policy Change Request

Your Name *

Your Email *

Your Phone Number *

Policy Number *

Your Company Name *

What Can We Help You With? *

What Policy Would You Liked Changed? *

Desired Effective Date of the Requested Change *

Please Describe Your Policy Change Request *

Type of Change

Add Vehicle

Vehicle Year *

Vehicle Make *

Vehicle Model *

Vehicle VIN *

Description of Vehicle Body Type (Example: Cargo Van, Flatbed, Pickup, SUV) *

Gross Vehicle Weight *

Any person or business entity operating a commercial vehicle with a Gross Vehicle Weight of 10,001 pounds or more is required to carry a Motor Carrier Permit (MCP).

Current Vehicle Value Including Any Permanently Attached Equipment or Vehicle Conversions *

Does the vehicle have any of the following? *

Does this vehicle have a converted bed? (example: Flat bed, Cargo bed, Stake bed) *

Yes
No

Description of the Converted Bed *

Cost of the Conversion *

Is There Any Equipment Permanently Attached to The Vehicle (Example: Ladder Rack, Tool Box, etc.) *

Yes
No

Description of the Equipment *

Value of Equipment *

Equipment not permanently attached may be insured separately via an Inland Marine Insurance policy. This may include construction tools and equipment. Please contact your agent for more information.

Garaging Address (Address Where Vehicle is Parked Overnight): *

Vehicle Use *

Business and Personal Use
Business Use Only
Personal Use Only

Radius of Operation (Miles): *

Average Number of Jobsite Visits Per Day Using this Vehicle *

0-1
2
3+

Is There a Lien Holder For This Vehicle? *

Yes
No

Lien Holder Name *

Lien Holder Address *

Do You Require Gap Insurance? (Not Available With All Insurance Carriers) *

Yes
No

Gap insurance is an optional coverage that can be added to your policy which may pay the difference between the balance owed on a lease or loan and what your insurance company pays if the vehicle is considered a total covered loss.

Vehicle Coverage

Do you want Comprehensive and/or Collision Coverage for this Vehicle? (We Recommend You Add These Coverages) *

Yes
No

Please Select Desired Comprehensive Deductible

Please Select Desired Collision Deductible

Do you want Rental Reimbursement Coverage? (Only available with Comprehensive and Collision added) *

Yes
No

Rental reimbursement “rental car coverage” is a type of optional coverage that helps pay for the cost of a rental car while your vehicle is being repaired after a car accident or after suffering damages that are covered through your policy. Not for pleasure use.

Desired Daily Reimbursement (30 Days Maximum) *

Do you want Towing Coverage? *

Yes
No

Towing Coverage only available with Comprehensive and Collision added. Towing Coverage pays for the cost of towing your car to the nearest repair shop when it is unable to be driven after a car accident and covers a specified amount of necessary labor charges at the place of breakdown.

Add Trailer

Trailer Year *

Trailer Make *

Trailer Model *

Trailer VIN *

Description of Trailer Body Type (Example: Flatbed, Dump Trailer, Semi-Trailer, etc.) *

Load Capacity *

Trailer (Greater than 2,000 lbs)
Service or Utility Trailer (Less than or Equal to 2,000 lbs)
Shop Made Trailer (Less than or Equal to 2,000 lbs)
Shop Made Trailer (Greater than 2,000 lbs.)

Value of Trailer *

Cost of Trailer New? *

Do you want Comprehensive and/or Collision Coverage for this trailer? (We recommend you add these coverages.) *

Yes
No

Please Select Desired Comprehensive Deductible

Please Select Desired Collision Deductible

Remove Vehicle or Trailer

Year *

Vehicle/Trailer Make *

Vehicle/Trailer Model *

Vehicle/Trailer VIN *

Reason You Would Like to Remove The Vehicle or Trailer From Policy? *

Add Driver

Full Name of Driver *

Date of Birth *

Gender *

Male
Female

Driver's License Number *

Issuing State *

Marital Status *

Number of Years With Driving Experience *

Relationship to the Insured *

Remover Driver

Full Name of Driver *

Reason You Would Like To Remove This Person From Coverage On The Policy *

Please Upload Any Documents Relevant to the Request.

Click or drag a file to this area to upload.

Opt-In

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Authorization

By clicking on the “submit” button below I acknowledge that I am an authorized representative/signer of the entity listed above and I am authorized to make changes on the insurance policies purchased through Integra Insurance Services.

Talk to an Agent: 907-376-3656