We enjoy serving you. Please fill out and submit the form below to reflect the changes you wish to incorporate in your policy. A represenative will be in contact with you shortley.
Manjoe Staff

| Change Automobile Policy Form |
| Fields marked with asterisks (**) are required. |
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This section allows you to delete a vehicle from your policy.
Please fill out the Policy Number and Policy Name Information, then enter changes for the appropriate section(s) below. Note Policy Name refers to the persons name on the existing Automobile policy.
This section allows you to add a vehicle to your policy.
Note: If the primary driver of the vehicle is not on the policy, please add them below.
To help answer the questions regarding the vehicle section following it will be useful to understand the terms.
Collision
Physical Damage coverage of covered autos for damage caused from a collision with another vehicle or object.
Comprehensive
Refered to below as Comp is physical damage coverage for insured autos which covers all risk other than those perils excluded and are not covered in collision.
Deductible
Refers to the dollar amount you must pay prior to coverage being paid for damages.
VIN
Vehicle Identification Number found on the vehicle either on the door drivers jam or the drivers side dash. This informaiton is also found on the vehicle title or registration.
This section allows you to add or delete a driver from your policy.
Maryland requires coverage for Uninsured Motorists to be the same limits as your Liability Limits. This limit will be amended as required by State Law.
NOTE: If Comprehensive Coverage is to be deleted, the Collision Coverage must also be deleted.
| New Vehicle (Make/Model/Year): | ![]() |
| Primary Driver of the Vehicles Full Name: | ![]() |
| Delete Collision for Vehicle(Make/Model/Year): | ![]() |
| Driver Full Name: | ![]() |
| Delete Comprehensive for Vehicle(Make/Model/Year): | ![]() |
| Driver License Number: | ![]() |
| Sate License Issued In(Maryland,Virginia): | ![]() |
| Dreiver Date of Birth: | ![]() |
| ** Effective Date: | ![]() |
| ** Policy Number: | ![]() |
| ** Policy Name: | ![]() |
| ** Email Address: | ![]() |
| Phone: | ![]() |
| Delete Vehicle (Make/Model/Year): | ![]() |
| New Vehicle VIN: | ![]() |
| If Other was selected for the disposition of the vehicle explain | |
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| Change Garaging Address To (include City ,State, Zip): | |
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| Lein or Lease holder ( Name, Address, City, State) | |
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| Change Billing Address To (include City ,State, Zip): | |
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| ** I Understand all changes in Coverage are subject to Underwriting approval by the Insurance Carrier who provides the coverage under your Homeowners Policy. Additional Information may be requested by the Underwriting Carrier before coverage can be considered to be effective.Coverage is not to be considered bound until all underwriting information requested by the Underwriting Carrier is received, accepted and approved.. Coverage is not to be considered bound until all premiums for the additional coverage is received, accepted and payments cleared. | ![]() |
| Vehicle Brakes: | ![]() |
| Primary Use: | ![]() |
| Vehicle Comp and Collision: | ![]() |
| Vehicle Comp/Collision Deductable: | ![]() |
| Change Medical Payments: | ![]() |
| Driver Change Options: | ![]() |
| Disposition of the vehicle | ![]() |
| Change Collision Deductable: | ![]() |
| Change Comprehensive Deductable: | ![]() |
| Change Liability Limits: | ![]() |
| Driver Marital Status: | ![]() |
| Vehicle Ownership: | ![]() |
| Vehicle Alarm: | ![]() |





