Richey ~ Barrett Insurance
A Professional Insurance Agency
Westlake, Ohio 44145 - 5611 Phone: (440) 835-4800 / Fax: (440) 835-6991
Report A Change: Auto
INSURED INFORMATION
Policy Holder's Name:
Residence Phone:
Your Name:
Business Phone:
Street Address:
E-Mail:
P.O. Box/Suite:
Cell #
City:
Fax:
State:
Zip Code:
ADD, REMOVE, OR CHANGE AN AUTOMOBILE
ADD A VEHICLE
Effective Date:
Purchased
Leased
Vehicle Year
Make
Model
VIN (17 digits)
Principal Operator
Garage Zip
Cost New $
FINANCED BY
(Loss Payee)
ADDITIONAL INSURED
(if different than Financing Company)
Name:
Additional Insured's Name:
Attention:
Attention:
Address:
Address:
City:
City:
State:
State:
Zip:
Zip:
REMOVE A VEHICLE
Effective Date:
Vehicle Year:
Manufacturer:
Model:
VIN (17 digits):
OTHER VEHICLE REQUESTS (including Coverage Changes)
Your change request will be acknowledged on the next business day.
Changes are not effective until confirmed by our office.
If you do not receive confirmation by our office, please contact us at
(440) 835-4800
.
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