Tanenbaum Harber

Request to Add or Delete a Vehicle

Insured's Name

Policy Number:

Effective Date of Change:

Add Vehicle:

Year

Make

Model

Identification Number

Cost New

If Private passenger; Driven to Work or School:

Under 15 Miles

Over 15 Miles

Pleasure

If Truck Indicate Gross Vehicle Weight and Use:	GVW	Use
	Radius of Operation:

When Adding a Vehicle, Indicate who is the Loss Payee and Address. If an Additional Driver Please Specify.

Certificate Holder:

Additional Insured

Loss Payee

Holder's Name, Address & Loan Number if Required:

Name
Street or P.O. Box
City
State
Zip
Phone
Fax Number
E-Mail

Driver's Name:	D.O.B.	State Licensed	Drivers License #



Delete Vehicle:	Year	Make		Model
	Identification Number		Cost New
Delete Vehicle:	Year	Make		Model
	Identification Number		Cost New

Comments:

Requested By: Date
E-Mail:

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)