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Add Driver to Existing Auto Policy


Fill out the following form as completely as possible. Once you have completed the form, click the Submit button to send your information. Your request will be handled promptly.

Personal Information
First Name
Required
Last Name
Required
Street
Required
City
Required
State
Required
ZIP / Postal Code
Required
Primary Phone Number
Required
Alternate Phone Number
Optional
E-Mail Address
Required
Policy Number
Required
Current Insurance Provider
Optional
New Driver Information
Name of Driver (First, Last)
Required
Gender
Required
Marital Status
Required
When will this change take effect?
Required
/ /
Relationship
Required
License State
Required
License Number
Required
Date of Birth
Required
/ /
Does this driver have any major violations (5yrs), accidents or minor violations (3yrs), comprehensive or collision claims (3yrs)?
Required
Submission Validation
Required
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Important Notice
Any submissions or payments made via this website do not constitute a binding agreement to your policy or coverages.  Changes and payments to policies are not effective or binding until you, or any party involved, receive official notice from either your insurance agent, or your insurance company.  Requested changes to your policies that remove or reduce coverage will require a signature from the insured.  Your agent will contact you to secure your signature. If you have any questions, please feel free to contact us.

Per the terms of our online privacy policy we will not resell your information to any third-party.

Affiliated with Lord and Associates Insurance Agency, Inc.