Add/Remove a Driver on my Policy

Add/Remove a Driver on my Auto Policy
Sign in to Google to save your progress. Learn more
* Required
Full Name: *
(Your name as it appears on your policy)
Your answer
Phone Number: *
Your answer
Email Address: *
Your answer
Effective Date of this Driver Change: *
MM
/
DD
/
YYYY
Add or Remove a Driver *
Choose
Add
Remove
Full Name of Driver *
Your answer
If ADDING new driver, what is his/her Gender?
Choose
Male
Female
If ADDING a new driver, what is his/her Date of Birth?
MM
/
DD
/
YYYY
If ADDING a new driver, list the relationship of this person to you:
Choose
Child of Policyholder
Spouse of Policyholder
Parent of Policyholder
Significant Other of Policyholder
Other Family Member of Policyholder
Other relationship
If ADDING a new driver, list DRIVERS LICENSE NUMBER and STATE that issued it:
Your answer
If ADDING a new driver, and he/she is a full-time student, list most recent Grade Point Average (GPA):
(4-point scale: A's=4.0 B's=3.0 C's=2.0 D's=1.0)
Your answer
If ADDING a new driver, which of your vehicles will this new driver primarily drive? *
(If you also need to add a vehicle, complete this form and follow instructions provided.)
Your answer
If REMOVING a Driver, list why he/she is being removed from your policy.
Choose
Moved out of Household
Secured his/her own coverage
No longer licensed or able to drive
Deceased
Other
Questions, Notes or Special Instructions:
Your answer
Submitting this information IS NOT a Policy or Binder of Insurance. No coverage will be bound until you receive confirmation from us.
BY CLICKING THE "SUBMIT" BUTTON BELOW, I CERTIFY THAT THERE IS NO PRE-EXISTING CLAIM, LOSS OR CIRCUMSTANCE LIKELY TO LEAD TO SUCH A CLAIM OR LOSS FOR WHICH I AM APPLYING FOR COVERAGE.
WARNING: ANY PERSON WHO KNOWINGLY AND WITH INTENT TO DEFRAUD ANY INSURANCE COMPANY OR ANOTHER PERSON FILES AN APPLICATION FOR INSURANCE CONTAINING ANY MATERIALLY FALSE INFORMATION, OR CONCEALS FOR THE PURPOSE OF MISLEADING INFORMATION CONCERNING ANY FACT MATERIAL THERETO, COMMITS A FRAUDULENT INSURANCE ACT, WHICH IS A CRIME AND SUBJECTS THE PERSON TO CRIMINAL AND [NY: SUBSTANTIAL] CIVIL PENALTIES. IN TN, VA AND WA, INSURANCE BENEFITS MAY ALSO BE DENIED.
NOTICE TO OHIO APPLICANTS: ANY PERSON WHO, WITH INTENT TO DEFRAUD OR KNOWING HE/SHE IS FACILITATING A FRAUD AGAINST AN INSURER, SUBMITS AN APPLICATION OR FILES A CLAIM CONTAINING A FALSE OR DECEPTIVE STATEMENT IS GUILTY OF INSURANCE FRAUD.

Questions? Contact:
Cameron A. Shandersky, CPCU
Schiff Insurance
P.O. Box 145496
Cincinnati, OH 45250-5496
P: 513.870.2580
cameron_shandersky@schiffinsurance.com
Submit
Clear form
Never submit passwords through Google Forms.
This content is neither created nor endorsed by Google. Report Abuse - Terms of Service - Privacy Policy
 
 


About Author

Cameron A. Shandersky, CPCU
Cameron's Bio