Request Change to Auto Policy

Please complete the following form and submit it. 

***Please note that GA Law requires that you return your gray registration from your vehicle before you take the vehicle off your insurance policy.  If you do not return the registration you may be subject to penalties imposed by the state.  For more information please contact your local tag office or visit the GA Department of Motor Vehicles web site for owner compliance information.   

Trade In Vehicle Description

New Vehicle Description

New Vehicle Use & Discounts

Please list any damage to vehicle including glass breakage.

**Note: Pictures may be required.

Driver Information

Additional Driver Information & Discounts

Please list all violations and accidents of the new driver (including not-at fault accidents) for the last 5 years:

Liability / Uninsured Motorists / Medical Payments

Please note that all Liability, Uninsured Motorist, and Medical payments must be the same for all vehicles.

Liability Limit - Bodily Injury Select $250,000 per person, $500,000 each accident $100,000 per person, $300,000 each accident $50,000 per person, $100,000 each accident $25,000 per person, $50,000 each accident $15,000 per person, $30,000 each accident
Liability Limit - Property Damage Select $100,000 each accident $50,000 each accident $25,000 each accident $10,000 each accident

Uninsured/Underinsured Motorists Limit Select $250,000 per person, $500,000 each accident $100,000 per person, $300,000 each accident $50,000 per person, $100,000 each accident $25,000 per person, $50,000 each accident $15,000 per person, $30,000 each accident None
Uninsured/Underinsured Motorists Property Damage Select $100,000 each accident $50,000 each accident $25,000 each accident $10,000 each accident

Medical Payments - Per Person Limit Select None $1,000 $2,000 $5,000 $10,000 $25,000 $50,000

Physical Damage Coverage & Deductibles

I understand that by requesting that a vehicle be taken off my policy I must turn the gray registration into the tag office before deleting the vehicle.  I also understand that if I do not turn the tag in I may be subject to fines and penalties imposed by the State Of GA.  Select No Yes

**Please note: that if you do not receive confirmation of policy changes from our office the change has not been made. You may need to contact us as soon as possible to be sure that the information we have is correct.

Submit Quote Reset Form

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