Bovard Insurance Group - Auto Change Form

Auto Change Form (Click here for .pdf file):

Insured's Name *

Phone Number *

Effective date of addition: *

Make *

VIN (Vehicle Identification Number) *

Cost new *

Year *

Model *

Customized features & extra value *

Gross vehicle weight *

Address garaged at: *

Line 1

Line 2

City

State

Zip Code

Country

Vehicle radius *

0 - 50 51 - 200 Over 200

Vehicle was: *

Purchased Leased

Loss payee/lienholder: *

Comprehensive coverage desired *

Yes No

Deductible *

Collision coverage desired *

Yes No

Deductible *

Effective date of deletion: *

Year *

Model *

Make *

VIN (Vehicle Identification Number) *

Requested by: *

First

Last

6950 Squibb Rd., Suite 200
Mission, KS 66202
(913)529-1130 phone
(913)529-1137 fax