Add / Delete Vehicle

Please read a following direction carefully.
After receiving your request, we will process it and contact you for confirmation as soon as possible.

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■ To add a new vehicle
Your signature is NOT required for this process.
Please submit this form and send one of the required documents* listed below to Daiwa Insurance via FAX or Email.

■ To delete a vehicle
Your signature is REQUIRED for this process.
Please fill out the form below and print. After you sign on the printed form, please send it to Daiwa Insurance via FAX or Email.

■ To replace a vehicle
Your signature is REQUIRED for this process.
Please fill out the form below and print. After you sign on the printed form, please send it to Daiwa Insurance via FAX or Email, along with one of the required documents* listed below.

*Required documents
  -  Sales Contract
  -  Registration
  -  Certificate of Title

FAX#：（310）540-6554
Email： info@daiwains.com

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* Required field

Name ： *

Phone Number (Home)： *

Phone Number (Work)：

Email：

Policy Number：

Effective Date： *

Month123456789101112

Day12345678910111213141516171819202122232425262728293031

Year1900190119021903190419051906190719081909191019111912191319141915191619171918191919201921192219231924192519261927192819291930193119321933193419351936193719381939194019411942194319441945194619471948194919501951195219531954195519561957195819591960196119621963196419651966196719681969197019711972197319741975197619771978197919801981198219831984198519861987198819891990199119921993199419951996199719981999200020012002200320042005200620072008200920102011201220132014201520162017201820192020202120222023202420252026202720282029203020312032203320342035203620372038203920402041204220432044204520462047204820492050

Type of Change： *

Add Vehicle

Delete Vehicle

Replace Vehicle

New Vehicle

Year：

Make：

Model：

Vehicle Identification Number：

Coverage：

Same as other vehicle in my policy

Change coverage

If changing a coverage, please describe：

Removing Vehicle

Year：

Make：

Model：

Vehicle Identification Number：

Signature ________________________________________   Date ___________________

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PRINT THIS FORM

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