Policy Change Request at Rider's Choice Insurance Agency, motorcycle, RV, Collectible vehicles

Policy Change Request

Please complete the “Policy Change Request” form below, providing information about your desired change per the following list of change types. Please NOTE that the insured’s signature is REQUIRED for coverage REDUCTIONS and for any vehicle/driver CANCELLATIONS. In these cases, please PRINT the form and mail/fax in to Rider’s Choice. For all vehicle/driver ADDS or coverage INCREASES, you may submit the change request on line. Rider’s Choice will contact you confirming receipt of your change request. No insurance coverage is bound until you
hear from Rider’s Choice.

Click here to download a form that can be printed and mailed to us in Word format.

Or, fill out the below form and hit "submit".

Name Phone
e-Mail address

Address

City State Zip

Existing Policy Number

Existing Insurance Carrier

Requested Effective Date of Change

Describe the policy change you are requesting. Indicate Type of Change from the list below.

Types of Changes:

To ADD a vehicle – provide year, make & model, VIN and engine size for new vehicle(s); complete coverage questions below.
To INCREASE or ADD coverage – complete coverage questions below for new coverage.
To ADD or CHANGE driver information – provide full name, birth date, gender, Drivers License number, and 3 year driving record.
To REDUCE coverage – complete coverage questions below for new coverage, sign, date, mail or fax in form
To DELETE or CANCEL a vehicle or the entire policy – provide year, make & model, VIN for vehicle(s) to be deleted, sign and date, mail or fax form.

Coverage:

Liability/PD Coverage? 20/40/15 25/50/25 50/100/50
100/300/100 250/500/250

Uninsured/Underinsured Coverage Same as Liability, unless requested otherwise.

Medical Payments? None 1000 2500 5000 10,000

Comprehensive (fire & theft)? Yes No
Deductible 250 500 1000

Collision? Yes No
Deductible 250 500 1000

Note: Rider’s Choice will contact you confirming receipt of your change request. No insurance coverage is bound until you hear from Rider’s Choice.

Voice 630-204-4178 Fax 815-732-1320
info@callriderschoice.com
P.O. Box 14 Oregon, IL 61061