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Add/Delete A Vehicle

Insured
Business Name
Date
Date Format: MM slash DD slash YYYY
Requestor Name & Contact Information (phone / email)
Delete Vehicle(s)
Vehicle Year
Make
Last 5 Digits of VIN
Effective Date of Deletion
Date Format: MM slash DD slash YYYY
Tags Transferred or Returned to MVA?
- Yes
- No
Add Vehicle
Add Effective
Vehicle Year
Make
Model/Body
Serial Number (VIN) must be 17 digits
Estimated Cost New
Gross Veh Weight (if over 10,000 lbs)
Garaging City/State
Usual Radius of Operation (50 / 100 / 100+ miles)
Primary Use
Name & Address of Individual or Entity in whose name vehicle is titled or leased (IF OTHER THAN INSURED)
Finance / Leasing Company Information
Vehicle Is (choose one):
- Financed
- Leased
- Neither
Full Name of Finance/Leasing Company as it should appear on the policy
Address of Finance/Leasing Company
Coverage Information
Liability limits same as other vehicles on policy?
Comp & Collision deductibles same as other vehicles?
Other (Towing, Rental, Lease/Loan Gap, etc)?
COMPLETE THIS SECTION ONLY IF INSURED IS PUBLIC AUTO OR TRUCKER (limo, bus, shuttle, trucker)
IF LIMO - Length
Seating Capacity
Commodity Transported
Stated Value (amt of insurance)
INSTRUCTIONS TO AGENT
- Fax
- Email Proof of Insurance to Dealership
Dealership Contact Info
- Fax
- Email
- Mail Auto ID Card to INSURED
Other Remarks or Instructions

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20251 Century Blvd, Suite 425
Germantown, MD 20874
Local: 301-417-0001
Toll-Free: 800-966-0001
Fax: 301-417-0040
customerservice@moodyinsurance.com