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All fields are required except where noted.


Auto Change Request
General Information
First Name:
Last Name:
Address:
City:
State:	Zip:
Telephone:	- -
EMail
Last 4 digits of your policy number:

Vehicle or Coverage Change
Type of Change:
If adding or deleting a vehicle, please complete this section. If you are trading vehicles, provide info about the new vehicle, and indicate which vehicle you are trading in the "other change" area below.
Year:
Make:
Model:
VIN:
Cost New:
Loss Payee
Name of principal driver of this vehicle:
How will you be using this vehicle?
Other Change (describe here):

Driver Change
Driver Name:
Date of Birth:	//
Drivers License Number
Check all that apply:	Honor Roll Student Driver's Ed Graduate
Bankname:

Any changes or editions will not take effect until confirmed by your agent. Coverage has not been bound by this submittal.

Turner Barker Insurance is a subsidiary of Gorham Savings Bank. Insurance products are offered through Turner Barker Insurance. Product offerings and insurance sold are not deposit obligations of, nor guaranteed by the Bank and are not covered by Federal Deposit Insurance.