Policyholder Request to Add and/or Remove Vehicle
POLICY NUMBER: _________________________________________
POLICYHOLDER’S NAME: ___________________________________
TELEPHONE NUMBER: _____________________________________
REQUESTED DATE: ________________________________________
☐ Add
☐ Remove
I understand that my request to add and/or remove the above vehicle(s) from my policy will be subject to state
law requirements, as well as the Company’s underwriting guidelines.
Special Note Regarding Back-Dated Removal Requests: The Company only allows back-dated requests to add
and/or remove a vehicle(s) on a policy in limited situations, which are subject to the Company’s underwriting
guidelines and state law. I understand that any such request to back-date a vehicle removal must be
accompanied by appropriate proof.
____________________________________________ ____________________
Policyholder’s Signature Date
____________________________________________ ____________________
Additional Named Insured (If Applicable) Date
To ensure timely processing, legibly complete this form in its entirety. You may fax this form to 1-888-888-0070.
For any questions regarding this form, please contact customer Service at 1-888-888-0080.
BWARV-01 (02/16)
