Automobile Change Form | Jack Bradley Agency

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706-778-2136

641 Irvin Street
Cornelia, GA 30531

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Automobile Change Form

Jack Bradley Agency

Please ensure you have policy pulled up in EPIC before starting the below form

Contact Information

JBA Staff Member Name ✶

Account Name

Policy Number

Requestor Name (Is this a named insured or spouse? If not, we will need to confirm before processing)

Phone Number (Best way to contact you TODAY)

Cell

Home

May We Text You Regarding Your Insurance

Yes No

Email Address

Effective Date

Date Change Taken

Effective Date of Change

Add Car

Year

Make

Model

VIN – carfax.com

Driver

Usage

Is car registered to named insured or spouse?

Yes No

If registered in a business name or LLC is it eligible to be added to this company?

Yes No

If registered to someone other than a named insured, is it eligible to be added to this company?

Yes No

Lienholder Information

Lienholder Name & Address

Leasing Company Name & Address

Coverage (Coverage Explanation)

Comprehensive

Yes No

Deductible

Full Glass

Yes No

Collision

Yes No

Deductible

Rental

Yes No

Limit

Towing

Yes No

Limit

Gap

Yes No

Replacement Cost

Yes No

Purchase Date (*required for GAP or Replacement Cost)

Original Owner (*required for GAP or Replacement Cost)

Yes No

OME Parts (*if available with carrier)

Yes No

Custom Equipment

Yes No

Additional Information

Delete Car

Year

Make

Model

VIN

Is car sold?

Yes No

If not sold remind customer to advise tag office

Tag office # is 706-754-2516

Additional Information (Reason for Deletion? Sold, inoperable, etc. Advised to Call Tag Office? Tag Already Canceled?)

Add Driver

Name

DOB

Drivers License (Please Obtain Regardless of Age)

M/S

Relationship

GS/DT

Additional Information

Reminder for Good Student and Drivers Training if needed

Delete Driver

Name

Reason

All Other Changes

All Other Changes

Follow Through

ID Card

Yes No

ID Card Pick Up or Email

ID Card Email to

Binder

Yes No

Binder Pick Up or Email

Binder Email to

Has this change been confirmed with the Named Insured

Yes No

Is there an umbrella?

Yes No

Has this change been processed?

Yes No

If yes – Confirmation Number

Special Instructions for Follow Through

Will be sent securely Your request will be sent securely over an SSL-encrypted connection

We respect your privacy. Your information will be sent securely and handled with care. View our privacy policy.

Note: leave the Subject field blank if you are a real person. If this field is filled in, your request will be ignored. This helps us protect against automated form posts (spam).
Subject

About Us

Jack Bradley Agency is an independent insurance agency with an office located in Downtown Cornelia..

Give us a call, stop by, or request a quote online to find out how much we can save you on your insurance.

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641 Irvin Street
Cornelia, GA 30531
706-778-2136
706-778-8598
info [at] jackbradley [dot] com
info [at] jackbradley [dot] com
Mon-Fri 8am-5pm

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