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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 *
Last Name *
Street *
City *
State *
ZIP / Postal Code *
Primary Phone Number *
Alternate Phone Number
E-Mail Address *
Policy Number *
Current Insurance Provider
New Driver Information
Name of Driver (First, Last) *
Gender *
Marital Status *
When will this change take effect? *
/ /
Relationship *
License State *
License Number *
Date of Birth *
/ /
Does this driver have any major violations (5yrs), accidents or minor violations (3yrs), comprehensive or collision claims (3yrs)? *
Submission Validation
Required

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.