Tanenbaum Harber

Request to Add or Delete a Driver

Insured Information
Named Insured:
Phone #:
Fax #:
E-mail Address:
Date of Change:
Add a Driver
Name of Driver:
Relationship:
DL #:
State:
Date of birth:
SS#:
Any Tickets?	Yes No
Defensive Driving Course?	Yes No
Drivers Training Certificate?	Yes No
Delete a Driver
Name of Driver:
Reason for deleting Driver:
Additional Information In the box below, please provide any additional information you feel may be necessary for this Auto Change Request form.

No Coverage may be added, changed, or bound as a result of submitting this request. All coverage must be confirmed by Tanenbaum Harber in writing, either via email or fax. If you do not receive a response from us within three working days, please call or email to confirm receipt of request. I have read and agree with the above disclaimer (It is mandatory to check box before request can be sent)