Massachusetts Personal Auto Policy Change To request a change, please fill out the form below. Please note, requests are not considered in force until you receive a confirmation from our office. Contact Information Name Address City/Town State Zip Phone Fax Email Best Contact Method Email Phone Fax US Mail Best Time Policy Information Policy Number Company Name Expiration Date Effective Date of Change Driver(s) - List all licensed drivers in your household. Driver 1 Name on License Date of Birth License Number State Driver Training Yes No Add / Remove Add Remove Driver 2 Name on License Date of Birth License Number State Driver Training Yes No Add / Remove Add Remove Driver 3 Name on License Date of Birth License Number State Driver Training Yes No Add / Remove Add Remove Driver 4 Name on License Date of Birth License Number State Driver Training Yes No Add / Remove Add Remove Coverages Part 3 - Bodily Injury By Uninsured Motorist No Change 50/100 100/500 250/500 500/500 Part 4 - Property Damage No Change $100,000 $200,000 Part 5 - Optional Bodily Injury No Change 50/100 100/500 250/500 500/500 Part 6 - Medical Payments No Change $25,000 Part 7 - Collision Deductible No Change No Coverage $300 $500 $1,000 Part 9 - Comprehensive Deductible No Change No Coverage $300 $500 $1,000 Part 10 - Substitute Transportation No Change No Coverage 15/day to 450 Max 30/day to 900 Max 45/day to 1350 Max Part 11 - Towing & Labor No Change No Coverage 50/incident 100/incident Part 12 - Bodily Injury By Underinsured Motorist No Change 50/100 100/500 250/500 500/500 Other Remove Secured Lender/Lienholder No Change Add Remove Principal Place of Garaging Change Mailing Address to Change Home Phone Number to Change Cell Phone Number to Disclaimer for Form: Please be advised that no coverage can be bound nor any changes made to your policy until confirmed in writing by an employee during regular business hours. If you have not heard from us within 24 hrs (excluding weekends & holidays), please let us know as we may not have received your information.
