Internal Policy Change Form – Purely Insurance

W. NIU Internal Policy Change Form

All personal lines policy change requests.

Internal Policy Change Request Form

EZLynxAppID
Email
Person Completing the Form*
- Rose
- Karen
Method Request was received*
- Phone Call
- Email
- Text Message
- Chat / Messenger
- EZLynx Notification
- Facebook
- Agent Generated
Policy Holder Name*
First Last
Email
Phone
EZLynx Account Overview
EZlynx or Infusionsoft URL
Notify Client of Ticket Submission?*
- Yes
- No
Please indicate the changes to be made*
- Replace a Vehicle
- Add a Vehicle
- Remove a Vehicle
- Add a Driver
- Remove a Driver
- Update Car Loan Info
- Change Coverages on a Vehicle
- Update Mortgage Loan Info
- Update / Change Address
- Cancel Policy
- Billing Question
- Other
Billing Questions
Select All that Apply*
- Question about Current Bill
- Question about Refund
- Update Payment Information
- Cancel EFT or Auto Payments
Cancel Policy
Cancellation Date
MM slash DD slash YYYY

(Leave blank for Client to fill out on DocuSign)
Policy(ies) to Cancel*
- Home
- Auto
- Renters
- Landlord / DP Policy
- Motorcycle / ATV
- RV / Travel Trailer
- Umbrella
- Life Policy
- Other (see notes)
Reason for Cancellation
- Better Price
- Poor Service
- No longer need Policy
- Other (see notes)
Add a Driver
Date Driver to be Added*
MM slash DD slash YYYY
Name of Driver to be Added
First Last
Does this person live at your address?*
- Yes
- No
What is their relationship to you?*
Marital Status?*
Date of Birth*
Month
Day
Year
Gender?*
Driver's License Number & State*
Social Security Number
All Tickets & Accidents*
Please list all tickets received (paid for or not) the last 3 years and accidents (at fault or not) the last 5 years. Type "None" if none.
Is the new driver a student?*
- Yes
- No
Does he/she have a 3.0 GPA or higher?*
- Yes
- No
Get the Discount
The Good Student Discount will be applied to your account once we receive a copy of the report(s) card or transcript(s).
Do you want to upload the report card(s) now?*
- Yes
- No, I'll send it in later
Upload Report Card(s)
Drop files here or

Accepted file types: jpeg, jpg, pdf, png, Max. file size: 7 MB, Max. files: 3.
Remove a Driver
Date driver to be Removed*
MM slash DD slash YYYY
Name of Driver to be Removed
First Last
Driver's Date of Birth*
Month
Day
Year
Reason for Removal*
- No Longer in Household
- Away at College
- In the Military
- On a Mission
- Has Own Insurance
- Other
Where do they now live & when did they move?*
Where are they going to school? How long will they be gone? and how often will they come home during the year?*
How long will they be gone? and how often will they come home during the year?*
How long will they be gone?*
Please explain*
Do they still live in your house?*
- Yes
- No
When did they Start their Policy?*
Month
Day
Year
Replace a Vehicle
remove a vehicle, add a vehicle
Date Vehicle to be Replaced*
MM slash DD slash YYYY
Vehicle to be Removed
Reason for Removal*
- Traded in
- Sold
- No longer operational
- Parked / Garaged
- Selling Vehicle
Vehicle to be Added*
VIN*
Verify the VIN by using: VehicleHistory.com or AutoDNA.com
Who is the vehicle registered to?*
Vehicle Use*
- Commute to work or school
- Pleasure
- Used for Business
Estimated Miles Driven Per Year*
Is this Vehicle Used for Rideshare (Uber, Lyft, etc.)?*
- Yes
- No
Is this Vehicle Used for any kind of delivery (Newspaper, Pizza, etc)?*
- Yes
- No
Does this vehicle have any existing damage?*
- Yes
- No
List existing damage*
Underwriting will require pictures of the vehicle damage. Please take 4-6 pictures and upload here or email to [email protected]
Comp Deductible*
(required if you have a loan/lease)
Collision Deductible*
(required if you have a loan/lease)
Do you want Rental Car reimbursement coverage?*
- Yes
- No
Do you want Roadside Assistance Coverage?*
- Yes
- No
Lien holder Information*
- I have a loan on this vehicle
- This vehicle is a lease
- There is no loan or lease on this vehicle
Bank or Credit Union name:*
Lease Company Name*
Are you interested in GAP coverage?*
- Yes
- No
Upload Vehicle Documentation
Drop files here or

Accepted file types: jpeg, jpg, pdf, png, Max. file size: 7 MB, Max. files: 5.
Please upload any documentation you have about your vehicle such as a purchase contract, registration information, etc.
Add a Vehicle
Date Vehicle to be Added*
MM slash DD slash YYYY
Vehicle to be Added*
VIN
Verify the VIN by using: VehicleHistory.com or AutoDNA.com
Who is the vehicle registered to?*
Vehicle Use*
- Commute to work or school
- Pleasure
- Used for Business
Estimated Miles Driven Per Year*
Is this Vehicle Used for Rideshare (Uber, Lyft, etc.)?*
- Yes
- No
Is this Vehicle Used for any kind of delivery (Newspaper, Pizza, etc)?*
- Yes
- No
Does this vehicle have any existing damage?*
- Yes
- No
List existing damage*
Underwriting will require pictures of the vehicle damage. Please take 4-6 pictures and upload here or email to [email protected]
Comp Deductible*
(required if you have a loan/lease)
Collision Deductible*
(required if you have a loan/lease)
Do you want Rental Car reimbursement coverage?*
- Yes
- No
Do you want Roadside Assistance Coverage?*
- Yes
- No
Lien holder Information*
- I have a loan on this vehicle
- This vehicle is a lease
- There is no loan or lease on this vehicle
Bank or Credit Union name:*
Lease Company Name*
Are you interested in GAP coverage?*
- Yes
- No
Upload Vehicle Documentation
Drop files here or

Accepted file types: jpeg, jpg, pdf, png, Max. file size: 7 MB, Max. files: 5.
Please upload any documentation you have about your vehicle such as a purchase contract, registration information, etc.
Remove a Vehicle
Date Vehicle to be Removed*
MM slash DD slash YYYY
Vehicle to be Removed
Reason for Removal*
- Traded in
- Sold
- No longer operational
- Parked / Garaged
- Selling Vehicle
Update Car Loan Info
Car Loan Update Type*
- Current Loan - bank or credit union needs proof of insurance
- New loan - update policy and send proof of insurance
- Loan Paid off - Remove Lien Holder info
Date of New Loan*
MM slash DD slash YYYY
Date to be Removed*
MM slash DD slash YYYY
Which Vehicle is the loan is associated with?*
Company Name*
Account # (if needed)
Company Mailing Address
Street Address City State Zip
Company Fax Number
Company Email Address
Upload Car Loan Info
Drop files here or

Accepted file types: jpeg, jpg, pdf, png, Max. file size: 5 MB, Max. files: 2.
Update Mortgage Loan Info
Mortgage Update Type (select all that apply)*
- Loan Sold - Update Mortgage Company Info
- Current Mortgage Company - Mortgage company didn't get the renewal notice
- Current Mortgage Company- Home Insurance wasn't paid, send payment request info
- Update Mortgage Company - Home Insurance Bill not paid, send payment request info
- Update Mortgage Company - Send them current Home Insurance Info
- Add 2nd Mortgage Lien Holder
Mortgage Company Name*
Account Number or Loan Number*
Address
Street Address City State Zip
Fax Number
Email
Upload Mortgage Documentation
Drop files here or

Accepted file types: jpeg, jpg, pdf, png, Max. file size: 5 MB, Max. files: 2.
Change Coverages on a Vehicle
Date for Coverage Update*
MM slash DD slash YYYY
Which vehicle do you want to change coverage on*
What Changes do you want to make?*
- Change Comprehensive Deductible
- Change Collision Deductible
- Change Liability Limits
- Change Roadside Service
- Change Rental Car Reimbursement Coverage
New Comprehensive Deductible*
New Collision Deductible*
New Liability Limits*
Roadside Service*
Rental Car Reimbursement*
Update / Change Address
Address*
Street Address City State Zip Code

Enter Updated or Changed Address. We will update the address on all policy(ies).
Additional Notes or Comments
Upload Supporting Documentation or Reports
Drop files here or

Accepted file types: jpeg, jpg, pdf, png, Max. file size: 7 MB, Max. files: 5.
This field is hidden when viewing the form
Notice of Agreement
- I understand that no changes will go into effect until an agent has reviewed the request to make sure it complies with my insurance company's underwriting guidelines and the change has been accepted by the company.

W. NIU Internal Policy Change Form

Internal Policy Change Request Form

Billing Questions

Cancel Policy

Add a Driver

Get the Discount

Remove a Driver

Replace a Vehicle

Add a Vehicle

Remove a Vehicle

Update Car Loan Info

Update Mortgage Loan Info

Change Coverages on a Vehicle

Update / Change Address