Please enable JavaScript in your browser to complete this form.Your Name *Your Email *Your Phone Number *Policy Number *Your Company Name *What Can We Help You With? *SelectI Need A Certificate of InsuranceAdd Additional InsuredAdd or Change CoverageUpdate Revenue, Employees, or Payroll FiguresOther Commercial Policy ChangeWhat Policy Would You Liked Changed? *SelectBusiness InsuranceCommercial AutoGeneral Liability InsuranceBusiness Owners InsuranceCommercial BondsCommercial Property InsuranceCommercial Umbrella InsuranceContractor InsuranceErrors and Omissions Liability InsuranceDesired Effective Date of the Requested Change *Please Describe Your Policy Change Request *Type of ChangeSelectAdd VehicleAdd TrailerRemove Vehicle or TrailerAdd DriverRemove Driver Add VehicleVehicle Year *Vehicle Make *Vehicle Model *Vehicle VIN *Description of Vehicle Body Type (Example: Cargo Van, Flatbed, Pickup, SUV) *Gross Vehicle Weight *Any person or business entity operating a commercial vehicle with a Gross Vehicle Weight of 10,001 pounds or more is required to carry a Motor Carrier Permit (MCP).Current Vehicle Value Including Any Permanently Attached Equipment or Vehicle Conversions *Does the vehicle have any of the following? *Ball at BumperFifth WheelBall in BedGooseneckTow BoomNoneDoes this vehicle have a converted bed? (example: Flat bed, Cargo bed, Stake bed) *YesNoDescription of the Converted Bed *Cost of the Conversion *Is There Any Equipment Permanently Attached to The Vehicle (Example: Ladder Rack, Tool Box, etc.) *YesNoDescription of the Equipment *Value of Equipment *Equipment not permanently attached may be insured separately via an Inland Marine Insurance policy. This may include construction tools and equipment. Please contact your agent for more information.Garaging Address (Address Where Vehicle is Parked Overnight): *Vehicle Use *Business and Personal UseBusiness Use OnlyPersonal Use OnlyRadius of Operation (Miles): *0-5051-100101-200201-300301-500500+Average Number of Jobsite Visits Per Day Using this Vehicle *0-123+Is There a Lien Holder For This Vehicle? *YesNoLien Holder Name *Lien Holder Address *Do You Require Gap Insurance? (Not Available With All Insurance Carriers) *YesNoGap insurance is an optional coverage that can be added to your policy which may pay the difference between the balance owed on a lease or loan and what your insurance company pays if the vehicle is considered a total covered loss.Vehicle CoverageDo you want Comprehensive and/or Collision Coverage for this Vehicle? (We Recommend You Add These Coverages) *YesNoPlease Select Desired Comprehensive DeductibleSelectSame Deductible as Current Vehicle(s) on Policy$250$500$1,000Please Select Desired Collision Deductible SelectSame Deductible as Current Vehicle(s) on Policy$250$500$1,000Do you want Rental Reimbursement Coverage? (Only available with Comprehensive and Collision added) *YesNo Rental reimbursement “rental car coverage” is a type of optional coverage that helps pay for the cost of a rental car while your vehicle is being repaired after a car accident or after suffering damages that are covered through your policy. Not for pleasure use.Desired Daily Reimbursement (30 Days Maximum) *SelectSame Rental Coverage as Current Vehicle(s) on Policy$30/Day$50/Day$100/DayDo you want Towing Coverage? *YesNoTowing Coverage only available with Comprehensive and Collision added. Towing Coverage pays for the cost of towing your car to the nearest repair shop when it is unable to be driven after a car accident and covers a specified amount of necessary labor charges at the place of breakdown.Add TrailerTrailer Year *Trailer Make *Trailer Model *Trailer VIN *Description of Trailer Body Type (Example: Flatbed, Dump Trailer, Semi-Trailer, etc.) *Load Capacity *Trailer (Greater than 2,000 lbs)Service or Utility Trailer (Less than or Equal to 2,000 lbs)Shop Made Trailer (Less than or Equal to 2,000 lbs)Shop Made Trailer (Greater than 2,000 lbs.)Value of Trailer *Cost of Trailer New? *Do you want Comprehensive and/or Collision Coverage for this trailer? (We recommend you add these coverages.) *YesNoPlease Select Desired Comprehensive DeductibleSelectSame Deductible as Current Vehicle(s) on Policy$250$500$1,000Please Select Desired Collision DeductibleSelectSame Deductible as Current Vehicle(s) on Policy$250$500$1,000Remove Vehicle or TrailerYear *Vehicle/Trailer Make *Vehicle/Trailer Model *Vehicle/Trailer VIN *Reason You Would Like to Remove The Vehicle or Trailer From Policy? *Add DriverFull Name of Driver *Date of Birth *Gender *MaleFemaleDriver's License Number *Issuing State *Marital Status *SingleMarriedSeparatedDivorcedWidowedNumber of Years With Driving Experience *Relationship to the Insured *OwnerEmployeeSpouseParentChildOtherRemover DriverFull Name of Driver *Reason You Would Like To Remove This Person From Coverage On The Policy *Please Upload Any Documents Relevant to the Request. Drag & Drop Files, Choose Files to Upload AuthorizationBy clicking on the “submit” button below I acknowledge that I am an authorized representative/signer of the entity listed above and I am authorized to make changes on the insurance policies purchased through Maverick Risk Partners.Submit
