TEST Change Request What can we help you with today?* Auto Policy Home/Condo Policy Renters Policy Motorcycle/Recreational Vehicle Policy Watercraft/Boat Policy Camper/Travel Trailer Policy Manufactured Home Policy Umbrella Policy Flood Insurance Business Owners Policy General Liability Policy Business/Commericial Auto Workers Compensation Policy Life Insurance Other Please select the policy you need to serviceWhat type of home/condo/flood change would you like to make?* Update Mailing Address ONLY Update/Add/Remove Mortgagee Change my coverage Change my deductible Cancel my policy Other *Signed requests to cancel must accompany "cancel my policy". First term policy cancellations are subject to an agency fee that must be paid prior to Wisco Insurance Company processing your request. Please indicate the location address of the property we are updating* What type of change would you like to make?* Update Mailing Address ONLY Update Mailing and Location Address Update Phone or Email Update/change coverage Cancel my policy Other *Signed requests to cancel must accompany "cancel my policy". First term policy cancellations are subject to an agency fee that must be paid prior to Wisco Insurance Company processing your request. What type of change do you need to make?* Add or Replace a Vehicle Add a Driver Add or Replace a Loss Payee/Lien holder Remove a Car Remove a Driver Change Coverage Change Address, Phone or Email Cancel my policy (signed request must be attached) Other Please select all that apply *Requests to cancel a policy must include an uploaded signed request. If an agency fee is required, we will not cancel the policy until the fee is paid. Please list all household members residing in home*Please list full legal name, date of birth and drivers license number. All household members are required to be listed on the policy. If you are living with someone who has their own insurance or is not driving please indicate that here. Please upload proof of insurance or email: email@example.comPlease indicate the vehicle/unit we are updating/changing.* Please indicate the driver we are removing* Are we Adding or Replacing a Vehicle?* Add Replace What is the reason for Removing/Replacing?* Sold/Traded Salvaged Vehicle Total Loss (Accident) Other Please select an answer below. Keep in mind, if you still own the vehicle and it is operational, we recommend leaving it on your policy. Please indicate the vehicle/unit we are removing* What is was the purchase price of the NEW vehicle?*Please enter the value or purchase price of the vehicle. What type of vehicle purchase did you make?* Loan Lease Cash Purchase/No Loan Please indicate your selection below. How will this vehicle be used?* Commute to work under 10 miles Commute to work 10-20 miles Commute to work over 20 miles I use this vehicle for work purposes Farm Secondary/Pleasure ONLY Seasonal Use Please indicate usage below. Please describe work usage.*Be specific! Is the vehicle used for any of these Ride sharing/delivery service?* Uber/Lyft Eat Street/Grub Hub Newspaper or Mail delivery Any other ride sharing or delivery None What coverage would you like?* Comprehensive/Collision "Physical Damage" Liability Only Comprehensive/Storage Only Liability and Comprehensive Please indicate your selection. If you desire policy add-on's such as roadside, towing, rental reimbursement, or equipment coverage you must select "physical damage". If you are interested in a towing/roadside package, please indicate that in other products you'd like to hear more about.Who will be driving the vehicle?* Please indicate all regular operators. Who titles the vehicle we are adding?* Please indicate all names listed on title of vehicle. What Comprehensive Deductible Would you like? $50 (Only available with some carriers) $100 $250 $500 $750 (Only available with some carriers) $1000 $2000 (Only available with some carriers) Other $100 with FULL GLASS (only available with some carriers) $250 with FULL GLASS (only available with some carriers) $500 with FULL GLASS (only available with some carriers) $750 with FULL GLASS (only available with some carriers) $1000 with FULL GLASS (only available with some carriers) $2000 with FULL GLASS (only available with some carriers) Keep in mind the HIGHER your deductible, the LOWER your premiums will be. Common perils covered by comprehensive: -Fire -Flood -Wind -Hail -Impact with Animals -Windshield/Glass -Theft -Vandalism (not by a colliding object) *See options w/FULL GLASS (no deductible for glass claims) *Check your policy for a detailed description of coverage*What Collision Deductible would you like?* $100 $250 $500 $750 (only available with some carriers) $1000 $2000 (only available with some carriers) Please indicate what collision deducitble you would like. Keep in mind, the HIGHER the deductible, the LOWER your insurance premiums are. Collision is for YOUR vehicle if you collide into an objectWhat other "Add-On" coverage would you like?* Towing/Roadside up to 50 miles Towing/Roadside up to 100 Miles Towing/Roadside over 100 Miles AAA Membership Rental Reimbursement $30/day Rental Reimbursement $40/day Rental Reimbursement $50/day Loan/Lease Payoff Custom Parts & Equipment (cover aftermarket additions) Car Key/Key Fob Replacement Other None Keep in mind, not all carriers offer all of the below options. Please select what you're interested in and one of our team members will notify you if your policy doesn't offer it.Are we Adding or Replacing your Loss Payee/Lien Holder* Adding Replacing Editing Existing Loss Payee/Lien Holder Information Please indicate your selection below: Why are we deleting this driver?* Moved out of household (not a college student) Divorce/Separation (Written Consent Required) Deceased (Death Certificate Required) Obtained Other Insurance (*Proof Required) Permanently Disabled (Proof Required) Surrendered License (Proof Required) Other Please indicate the reason below. Keep in mind removing a driver (depending on the reason) may require additional documentation for underwriting. We will contact you to notify you if that documentation is required. *WE CANNOT REMOVE HOUSEHOLD MEMBERS UNLESS THEY QUALIFY FOR ONE OF THE REASONS LISTED. IF YOU SELECT OTHER INSURANCE, WILL WILL NEED PROOF TO FINALIZE YOUR REQUEST. COLLEGE DEPENDENTS NEED TO BE LISTED ON YOUR POLICY FOR HOLIDAY AND SUMMER BREAKS. What vehicle/unit are we adding/editing loss payee information for?* Loss Payee/Lien Holder*Please indicate the full bank name, address for insurance department, loan number (if applicable). If proof of insurance is being requested please include an email or fax# where that needs to be sent- otherwise a copy will go out via mail. What is the VIN for the NEW vehicle?* Vehicles post 1980 will have a 17 digit VIN. Please verify you are sending the correct VIN, or we cannot complete your change.If you selected "Other" Please indicate what we can help you with:*Please verify Year, Make, Model of NEW vehicle* Please verify the details of your vehicle addition. What address is the vehicle being kept at?*Is there any damage on the vehicle you are adding?* Please let us know if there is any existing damage to your vehicle. Please note, we may need photos of your vehicle if you are requesting physical damage. What is the odometer reading on your vehicle?* What is the full legal name of the driver we are adding? Please include first, middle initial, and last name. What is the date of birth of the driver we are adding?* Please provide drivers license number and issuing state* What is the driver's occupation?* What is the gender of NEW driver?* Male Female What is the marital status of the NEW driver?* Single Married Divorced Widowed Civil Union What is the drivers highest level of education?* What vehicle will driver be operating?* Indicate any discounts this driver may qualify for* Good Student (3.0 GPA or better) Defensive Driver Course Military Student away at college without vehicle (more than 100 miles) Clean Driver (5 years) How will the driver be using the vehicle?* Commute work/school Pleasure/secondary operator Business/Used FOR work purposes Uber/Lyft/Ridesharing/Delivery What changes are you looking to make on your life insurance?* Update Beneficiary Change Coverage Amount Update Contact Information Update Billing Information Other Policy Number Leave blank if not available.Please give us the details of your request:*Be specific! Name* First Last Address* Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Email* Phone*What is the effective date/purchase date of your change?* MM slash DD slash YYYY I am interested in hearing more about: Auto Insurance Home Insurance Umbrella Insurance Motorcycle/Rec vehicle Insurance Watercraft/Boat Insurance Life Insurance AAA Business/Commercial Insurance Other None Please identify any of the below products we may be able to assist you with! Please upload any pertinent documents Drop files here or Select files Max. file size: 98 MB. CommentsThis field is for validation purposes and should be left unchanged.