Greenwood Insurance Group [Customer Resources



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Policy Holder Information
Fields marked with (*) are required

*Name of Insured

*Phone

*E-mail Address

*Effective Date of Change

Lien Holder Information
Note: Only complete this section if updating or changing lien holder information.

Lien Holder

Address

Address 2

Phone

Fax

Loan Number

If Adding a Vehicle

Primary Driver

Make

Model

Year

VIN

Cost

Anti-Lock Brakes

	No
	Yes

Air Bags

	None
	Driver
	Driver/Passenger

Anti-Theft Device

	No
	Yes

Primary Use

	Farm
	To/From Work
	Business
	Car Pool
	Pleasure

If Removing a Vehicle

Make

Model

Year

VIN

If Adding a Driver

Name

Relationship

Drivers License Number

Date of Birth

Defensive Driving Certificate?

	No
	Yes

Drivers Training Certificate?

	No
	Yes

If Removing a Driver

Name

Reason

Additional Comments

Please provide any additional comments or instructions you may have.

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Sending Greenwood Insurance Group e-mail does not constitute a binding confirmation of new or altered insurance coverage. Written confirmation must be obtained from Greenwood Insurance Group to confirm binding or altering coverage.

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"Your office has always answered all calls promptly and assisted with problems in a very professional manner. Thank you! "

- Karen Gossett

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