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952-479-5877
2431 Galpin Ct #140
Chanhassen, MN 55317
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Add or Remove a Vehicle
from Active Insurance Solutions
First & Last Name
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Phone
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Email
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Name on Policy
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Desired Effective Date
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Type of Change
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Add a Vehicle
Remove a Vehicle
Replace a Vehicle (add one + remove one)
Vehicle to Remove
Year
✶
Make
✶
Model
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Vehicle to Add
Year
✶
Make
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Model
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Primary Driver Name
VIN
Required to complete this change
Name on Title
Purchase Date
Ownership
Lease
Loan
Own
Loan/Lease Company Name & Address
(if applicable)
Do you want GAP Coverage included?
Protects you if car value in the event of a total loss is LESS than the amount owed on the loan/lease. This is most relevant for brand new cars, or newer cars with little to no down-payment.
Yes
No
Not Sure (I would like to discuss)
Desired Coverage
✶
Full Coverage (Liability, Comprehensive, and Collision)
Liability Coverage Only
Not Sure (I would like to discuss)
Other
Additional Information
Is it ok for Active Insurance Solutions to use text messages to communicate with you, as outlined in
our agency text message rules and regulations
?
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Yes
No
I understand that insurance coverage is not bound or altered until I receive confirmation by an authorized representative of Active Insurance Solutions
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