Add/Remove Vehicle or Change Loss/Payee
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Please note we cannot bind coverage from an email or voicemail request. Coverage is bound after you receive a written email or telephone confirmation from Peak Insurance Group.




Select One:
 Change Inquiry
Policy Number:

Your Name (required):

Email Address:

Daytime Phone Number (example: 5555555555 – no dashes)

Select One:
 Please call to discuss my policy See change information below
Change Loss Payee:

DELETION (Only complete if you are removing a vehicle)
Year:

VIN:

Make/Model:

Reason for Deletion:
 Sold Stored Traded Other

ADD VEHICLE
Year:

VIN:

Make/Model:

Owner:

Primary Driver:

Describe Use:

COVERAGE REQUESTED
Same Coverage as Deleted Vehicle?
 Yes No
See Additional Coverage Selections Below:
 Yes No

ADDITIONAL COVERAGE (Please use other comments area below for any desired coverage not listed here.)
Towing
 Yes No
Grange Personal Auto Plus
 Yes No
Rental Reimbursement: (You must have collision coverage in order to select Rental Reimbursement)
 Yes No
Loan/Lease Gap: (Your vehicle can be no more than 3 years old to be eligible for this coverage.)
 Yes No
Anti-Lock Brakes:
 Yes No
Anti-Theft Alarm:
 Yes No
Airbags:
 0 1 2
ADDITIONAL INTEREST, IF ANY:
Bank Loan:
 Yes No
Leaseholder:
 Yes No
None:
 Yes No
Other:
 Yes No
Add:
 Yes No
Change:
 Yes No
Delete:
 Yes No
New Name:

Address:

City:

State:

Zip:

Inquiry or Other Comments:

GET IN TOUCH

Have a question or feedback? We’d love to hear from you!

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