Auto Change Request Form

Auto Insurance Change Request Form

Please answer as best you can, and email us at service@insurancemh.com (or text us at 850-329-6996) if you feel you need to include any additional information or have questions about how you answered any question. We can make changes prior to actually finalizing your change.
Name*

First NameMiddle InitialLast NameSuffix
What is your best phone number?*
Please enter a valid phone number.
What is your best email address?*
example@example.com
What day are we making this change effective? (at 12:01am the morning of xyz date)*

MonthDayYear
Date
Is this vehicle replacing a vehicle on the policy?*
What is the Year Make & Model of the vehicle you traded in
What is the Year Make & Model of the vehicle you purchased*
Does it have Anti-lock brakes?*
What kind of alarm system does it have*
If you can, please take a photo of your vin from your car windshield, door, or purchase documents (this just helps us make sure it's right) OR, enter your vin number twice in the next question.
If you did not take a picture of the VIN, what is the VIN # of the vehicle you purchased (otherwise, skip)
Please double check this, it's important this is correct - It will be exactly 17 characters, and there will be no "L" or "i" characters and anything that looks like an "O" is a "zero"
For verification, please RE-enter the VIN # of the vehicle you purchased (Skip if sent photo)
Please double check this, it's important this is correct - It will be exactly 17 characters, and there will be no "L" or "i" characters and anything that looks like an "O" is a "zero"
Also, because it is REALLY important that we get the 17 digit VIN# correct, it's a good idea to go ahead and check your VIN against the state DMV database, when you can, here: https://services.flhsmv.gov/MVCheckWeb/
How did you pay for the new vehicle*
Name of the Lessor or Lienholder*
Address of Lessor or Lienholder if you know it
First and Last names of everyone on the vehicle title*
Anyone besides you and/or your spouse on the title?*
Name of person who will typically drive this vehicle*
Does this person reside in your household?*
Address of person not in household driving this vehicle *
ONE WAY distance to work or school of the person who will typically drive this vehicle *
Best guess on mileage is completely fine
Anyone besides you, your spouse, or other household members going to drive this vehicle?*
Name & Address of person not in household driving this vehicle *
Will this vehicle be used for, delivery of any people or products, or any uber/lyft or other ridesharing?*
Do you, or anyone in your household, have any vehicles that are co-owned by anyone NOT living in your household?*
Are you, or anyone in your household, a co-signer of any vehicles? *
Do you own anything else with a motor or wheels, other than lawnmower, like an ATV, Side-by-side, Motorcycle, Golf Cart, Scooter, RV, Camper, Trailer, Jet Ski, Boat, etc?*
What do you own?

ATVSide-by-Side (UTV)MotorcycleGolf CartScooterMotor HomeCamping Trailer/Pop Up TrailerUtility TrailerJet SkiBoatTractor/Major Lawn & Garden EquipmentOther
Any questions or anything else important that you think we should know about this?
In order for us to best help you, and give guidance appropriate to your specific household, can you take about 90 seconds (not required, but important) and answer a few last questions? This helps us tailor your coverages specifically to what you need and make sure you're not paying for something you really may not want, and make sure we're not missing anything you might find valuable?
This isn't to sell you junk you don't need. If we know what IS and ISN'T important to you, we can custom fit the policy and coverages to provide you the most possible value. You're unique; your coverage should be too.
If it saves an appropriate amount of money vs the risk, how high of a deductible can you handle WITHOUT it being a burden?
If one of your vehicles were not driveable for a month, would it be a problem or could you go about your normal daily activities?
If things go well this year, what is your annual household income?
Best guess is fine - this helps us give guidance on which levels of liability protection and uninsured motorist we should have you consider (this means up or down, since we dont want to assume what you set up previously is still best today)
If you or your family are badly injured in a car accident, how important is it to have compensation (money) available from your policy?
Half of all cars have LESS than $30,000 of insurance or assets to compensate you for damage they do to you (pain, lost wages, loss of limb or sight, etc)
Ages of all of your children
Would you like to add accident forgiveness to keep your rate from increasing after a claim?
Generally cost is about 2-3% of your current rate. Answering this wont make the change - this just lets us know if you'd like us to talk about it or not
It is important to get OEM parts if your vehicles is damaged or be paid 10% above the repair value?
Please verify that you are human*
Remember, no coverages can be bound, changed, or cancelled until you get confirmation from a licensed agent of the McGinniss Himmel Insurance Agency, LLC. This form allows us to more accuratly and quickly help get you taken care of but submission of this form does not confirm or change your coverage. We OFTEN can respond to these within 2-4 business hours, but please allow us 24 hours (Monday-Friday) to review and contact you with options and confirmation of coverage.
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Auto Insurance Change Request Form