Ricketson Insurance and Realty




	Ricketson Insurance
	and Realty, Inc.

Request Quote for changes to Auto Policy

Please complete the following form and fax it to one of our four branch offices at the fax numbers listed below. Someone will contact you shortly with the requested information.

Thomson	Warrenton	Wrens	Martinez
706-595-9225	706-465-3314	706-547-0005	706-863-4783

***Please note that vehicle or coverage changes can not be processed with out the insured's signature and date at the bottom of this form..***

Name of Insured:
Address:
Address:
City:
Zip:		State:
Phone Day:		Eve:
E-mail Address:		Fax:

Dealership Information

Dealership Name
Person Requesting
Address
Address
City
State
Zip
Phone #
Fax #

Trade In Vehicle Description

Year	Make & Model - Please Be Specific

Body Style	Vehicle ID# (Must be exact)

Newly Purchased Vehicle Description

Year	Make & Model - Please Be Specific

Body Style	Vehicle ID# (Must be exact)

Purchase Price

Newly Purchased Vehicle Use & Discounts

Vehicle Usage	Miles One Way	Driver Name

Airbags	Anti Lock Brakes	Auto Seat Belts

Driver Information For New Vehicle

Driver	Driver Name
1.

Is there a lien holder or additional insured that need to be listed on the policy?

Yes No

If yes, how are they to be listed?

Lien holder Additional Insured Lien Holder & Additional Insured

Lien Holder / Additional Insured Information

Lien Holder
Address
Address
City
State
Zip
Loan #

Please list all custom parts and equipment.

Liability / Uninsured Motorists / Medical Payments

****Please note Liability / Uninsured Motorists / Medical Payments limits must be the same for all vehicles on one policy. Leased vehicles may be required to carry a higher liability limit.****

Liability Limit - Bodily Injury
Liability Limit - Property Damage

Uninsured/Underinsured Motorists Limit
Uninsured/Underinsured Motorists Property Damage

Medical Payments - Per Person Limit

Physical Damage Coverage & Deductibles (New Vehicle Only)

Comprehensive Deductible	Collision Deductible	Towing	Rental

Additional Information

Is there any existing damage to the vehicle? (Please include glass damage)

Yes No

Describe in detail any damage to the vehicle. Pictures will be required.

___________________________________	____________________
Insured's Signature	Date

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Ricketson Insurance & Realty Inc.
P.O. Box 921 - 955 Augusta Rd.
Thomson, GA 30824
Phone: (706) 595-4354
Toll Free: (800) 613-5874
Fax: (706) 595-9225

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September 21, 2005

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