Alabama – Garland Insurance

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Customer Service Request Type?*

Is your request for you Personally or for your Business?

Account Email Address?*

Personal Customer Service Request?*

Tell us what type of Personal Service Request we can Help You With!

Business Name?*

Name*

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Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

Primary Phone Number?*

Alternate Phone Number?

Homeowners Insurance Request

Request Declaration and Coverages for Existing Homeowners Insurance Coverage

Personal Request Type?*

How can we help?

Business & Commercial Request Type*

What is the Name of Your Insurance Provider*

What is Your Policy Number?*

Year of the New Vehicle*

Make of the New Vehicle*

Model of the New Vehicle*

How Many Cylinders?*

VIN #

What Type of Coverage?*

Tell us what type of coverage you want to have for this new vehicle!

Comprehensive Deductible*

Collision Deductible*

Ownership*

Tell us if you are Financing, Leasing or Own the new vehicle you are adding to your policy!

How many miles will you drive your car annually? (Approximately)

What percentage of your vehicles total use time is driven by you?

Name of New Driver?*

First Last

Tell us who is going to be a new driver on your existing policy!

Gender*

Marital Status?*

When will this change take effect?*

MM slash DD slash YYYY

Relationship to the New Driver?*

What State is the New Driver Licensed In?*

State

Drivers License Number*

Any Recent Driving Violations or Accidents?*

Does this driver have any major violations (5yrs), accidents or minor violations (3yrs), comprehensive or collision claims (3yrs)?

Lein Holder Company Name?*

Lien Holders Address

Street Address Address Line 2 City State ZIP Code

Lien Holder Phone Number?

How Do You Want the Declaration Page Sent To You*

US Postal Mail Service

Fax

Fax Number*

How Do You Want Your ID Cards Sent To You?*

US Postal Mail Service

Fax

Fax Number*

Name of Requesting Company?*

Address of Requesting Company?*

Street Address Address Line 2 City State ZIP Code

Primary Phone Number of Requesting Company?*

Alternate Phone Number?

Fax Number of Requesting Company?

Requesting Company Contact Email Address?

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