Paulson Auto Change | BenefitSource Insurance Services

Your Information

Name*

First Last

Email

Do you need to update your contact information?*

Auto/Driver Change

Request Type:*

Quote Only
Ok to process change

Select Auto/Driver Change*

Add a Driver

Full Name on Driver's License*

Date of Birth*

MM

DD

YYYY

Gender*

Driver's License #*

Driver License State*

State

Date First Licensed*

MM

DD

YYYY

Relationship to primary Insured listed above:*

Marital Status:*

Occupation*

Which vehicle does this driver primarily use?*

Work/School Name*

Work/School Address*

Street Address Address Line 2 City State ZIP Code

Discount Check. Do you qualify for any of the following?*

4 Year Degree
Professional
Good Student
Government Employee
N/A

4-Year Degree Type*

Professional Title/Industry*

Good Student GPA, etc*

Government Branch/Section*

Add a Vehicle

Year Built*

Make*

Model*

VIN #*

Current Odometer Reading*

Date of Purchase*

MM

DD

YYYY

Registered Owner*

Primary Driver*

How will this vehicle be used?*

How many miles do you drive this vehicle per year?*

How many miles is this vehicle driven to work/school (one way)?*

How many days per week?*

How many miles do you drive this vehicle per year?*

What is the maximum driving radius?*

Do you use this vehicle for ride sharing such as Uber or Lyft?*

Where is this vehicle normally parked/located?*

Address where vehicle is normally parked/located?*

Street Address Address Line 2 City State ZIP Code

Did you buy this vehicle:*

New
Used

Do you have any Non-Factory Equipment installed on this auto?*

List Non-Factory Equipment*

Approximate Cost of Non-Factory Equipment*

Do you require Original Manufacturer Parts if this vehicle is damaged?*

If this is a New Vehicle, would you like to add Gap Coverage if your insurance company offers it?*

Do you wish to have Rental Car coverage?*

Do you want Roadside Assistance Coverage?*

Do you have any Usage and/or Annual Mileage changes?*

Please explain Usage and/or Annual Mileage changes.*

Coverage Selection*

Delete a Driver

Full Name of Driver*

Driver's Relationship to You*

Is the Driver Completely out of your Household?*

Does this Driver have any ownership to any vehicle on your policy?*

Will this Driver continue to have access to, or drive any Vehicle on your policy?*

Effective Date to Delete*

MM

DD

YYYY

Reason for Deletion*

Delete a Vehicle

Year*

Make*

Model*

Effective Date to Delete*

MM

DD

YYYY

If you have similar autos, provide last 4 digits of VIN # for the Vehicle that you want removed from your policy.

Reason for removing coverage?*

Do you have any concerns that need to be addressed? Please leave a note.

Phone

This field is for validation purposes and should be left unchanged.

Paulson - Auto Change Request

Your Information

Auto/Driver Change

Add a Driver

Add a Vehicle

Delete a Driver

Delete a Vehicle