Replace a Vehicle

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Replace a Vehicle

Contact Information

Current Auto Policy Number:
Name on Policy:
Full Name:
Email Address:
Daytime Telephone Number:

Vehicle Being Replaced: Change of Name - Change of Address - Request Certificate of Insurance - Add or Delete Loss Payee/Mortgagee - Property Policy Change Request Auto ID Cards - Add a Vehicle Form - Remove a Vehicle from Existing Policy - Replace a Vehicle on Existing Policy
Old Vehicle Make:
Old Vehicle Model:
Old Vehicle Year:

New Vehicle Information:
Effective Date of Policy Change:
VIN#
Year of New Vehicle:

Make of New Vehicle:
Model of New Vehicle:
Is this a purchase or lease:	Purchase Lease
Body Type of New Vehicle:
Title Holder/Register Owner:
Name of Principal Driver:
Principal Driver's Relationship to Named Insured:
Occasional Driver/Operator:
Purchase Price:
Lien Holder/Loss Payee Name:
Lien Holder Address:
Garage Address:

New Vehicle Desired Coverage:
Vehicle Usage: (describe)
Miles to work: (one way)
Deductibles:	Comprehensive Collision
Anti-Lock Brakes:
Car Alarm:
Air Bags:
Rental Coverage:
Towing Coverage:
Additional Comments:
Please Note: Insurance coverage cannot be bound without a written binder from our office.

A.F. Szabo Insurance Agency, Inc.
11705 Berry Rd. Suite 101
Waldorf, MD 20603
Office: 301-645-8545 - 1-800-828-3645
Fax: 301-645-0912

Hours of Operation:

Monday through Thursday 8:00Am to 4:30PM Friday 8:00am to 2:00PM