Auto Rental Insurance Change Request

Please complete the form below and a customer service representative will contact you shortly. If you have any questions, please call 800-782-8902 x3314 or email us at rental-service@lancerinsurance.com.

Company Name:

Contact Name:

First Name

Last Name

Phone:

(###)

###

####

Vehicle #1 Change:

Liability:

Add

Delete

Effective Date:

YYYY

Physical Damage:

Comprehensive

Collision

Company Vehicle Number:

VIN:

Year:

Make:

Model:

Seating:

Value:

Vehicle's current value

Vehicle #1 Loss Payee/Additional Insured Information

Payee or Additional Insured:

Loss Payee

Additional Insured

Payee or Additional Insured Name:

Payee or Additional Insured Address:

COVERAGE IS AFFORDED AS SPECIFIED IN THE POLICY LISTED ABOVE.