Service Request Form

Client Information

Name(Required)

First Last

Email(Required)

Phone

Which Policy Do You Need To Service?

What Other Type of Insurance?(Required)

Please Select The Home Changes You Need To Make

Change Mortgage Company

Add More Personal Property Coverage

Change Your Mailing Address

File A Claim

Document Request

Other

Billing Inquiry

Please Select The Auto Changes You Need To Make

Add/Remove/Replace A Car

Add/Remove Driver

Add/Remove/Update Lienholder

Update Your Address

File A Claim

Billing Inquiry

Document Request

Other

Mortgagee Update

New Mortgagee Name(Required)

Loan Number(Required)

New Mortgagee Address(Required)

Street Address Street Line 2 City State ZIP Code

Mortgagee Clause(Required)

ATIMA

ASAOA

ATIMA/ASAOA

Personal Property Coverage

What type of personal property coverage change would you like to make?

Increase total personal property coverage limit

Add specific item(s) of value (scheduled property)

How much more personal property coverage would you like to add?

Please list the specific items that should be added to your policy

Item Description

Replacement Value

Date Purchased

Update Address

New Mailing Address(Required)

Street Address Address Line 2 City State ZIP Code

Why are you updating your address?(Required)

This is my new residence

This is only a mailing address (I still live at my current address)

Update Address

Updated Address(Required)

Street Address Address Line 2 City State ZIP Code

Why are you updating your address?(Required)

This is my new residence

This is only a mailing address (I still live at my current address)

Other Changes

Please Specify Your "Other" Changes. Be As Specific As Possible

Vehicle Changes

Which action are you requesting?(Required)

Add a new vehicle to my policy

Remove a vehicle from my policy

Replace a vehicle on my policy with a new vehicle

Vehicle to Remove

Which Car Are You Removing? (Yr, Make, Model)(Required)

Reason For Removal?(Required)

Sold

Other

What day did you stop owning the vehicle?(Required)

MM slash DD slash YYYY

Vehicle to Add

What Is The 17 Character VIN# Of Your New Car?(Required)

Please double check your entry to make sure it's correct. Also note VINs never contain the letters L or O (if you see them they are 1 or 0).

How Will The New Car Be Used?(Required)

Pleasure

Work/School Commute

Business/Commercial (Including Uber and Lyft)

How Many Miles Will This Car Be Driven Annually?(Required)

The average commuter will drive approximately 13,000 miles a year.

What Is The Odometer Of Your New Car?(Required)

What Date Did You Purchase The Vehicle?(Required)

MM slash DD slash YYYY

Does Your New Car Need Comprehensive & Collision Coverage?(Required)

Yes

Is their a Lienholder?(Required)

Yes

Lienholder Name(Required)

Address(Required)

Street Address Address Line 2 City State ZIP Code

Who Is The Primary Driver?(Required)

New Vehicle Deductibles

What Comprehensive Deductible Would You Like?(Required)

$250

$500

$1000

Decline Comprehensive Coverage

Comprehensive covers everything other than an at fault accident. Ex. Theft, vandalism, a rock cracking your windshield on the freeway, etc.

What Collision Deductible Would You Like?(Required)

$250

$500

$1000

Decline Collision Coverage

NOTE: The lower the deductible, the higher the premium.

Add/Remove Driver Information

Which driver action are you requesting?(Required)

Add a new driver to my policy

Remove a driver from my policy

New Driver Information

New Driver Full Name(Required)

New Driver Date of Birth(Required)

MM slash DD slash YYYY

New Driver DL#(Required)

New Driver's Relation To You(Required)

Other Relation

Does new driver live with you?(Required)

Yes

New Driver's Employer or School

Current High School Student With A 3.0 or Better GPA?

Yes

If the new driver is a high school student with a 3.0 or better GPA, they may qualify for a "good student discount". You will need to submit proof (last report card).

New Driver's Address(Required)

Street Address Address Line 2 City State ZIP Code

Removed Driver Information

Name(Required)

First Last

Reason For Removing Driver(Required)

Is This Person Still A Household Resident?(Required)

Yes

Document Request

Which Document(s) Are You Requesting?

When Do You Need The Document(s)?

MM slash DD slash YYYY

If you need your documents urgently please click the link below and navigate to your insurance carrier's website or service phone number.
https://www.smithdavisinsurance.com/carriers/
If this is not a time-sensitive request our team will have your documents emailed to you in less than 24 business hours.

Business Policy Changes

Business Name(Required)

Name of person submitting request(Required)

First Last

Email(Required)

Phone

Business Policy(ies) Needing Service(Required)

BOP

Business Auto/Fleet

Business Liability

Business Property

Cyber Liability

Excess Liability

General Liability

Workers Comp

Other

Other Type of Policy(Required)

Do you need to file a claim or request a COI?(Required)

File A Claim

Request A COI

Other Type of Change

Please explain the details of your request.(Required)

Please upload any files required to make the change.

Max. file size: 39 MB.

Claim Information

Date of Loss(Required)

MM slash DD slash YYYY

Details of the claim you would like to file.(Required)

Consent(Required)

I understand that the purpose of completing this form is to inform Smith Davis Insurance about a claim I would like to file. I also understand that completing this form does not constitute filing a claim with my insurance carrier.

Smith Davis Insurance will use this information to evaluate my claim and advise me about filing a claim.

Agreement(Required)

I understand that submitting this form does not actually make any changes to my policy. This form is only a request and no changes to my policy are effective until I receive confirmation from Smith Davis Insurance or my insurance carrier..

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