The Paul F. Tilly Agency, LLC.
1891-1897  Rochester St , P.O Box 37A,  Lima, NY  14485  
Phone: (585) 582-1660               Fax: (585)582-1018               
 Auto  Home Business Life  Recreational Vehicles  Quotes Companies Policy Services Our Staff Contact Us Community  Home
 
 

The following companies offer 24/7 services online:   
New York Central Mutual

A Central

Progressive

Travelers

AutoOne

American Modern Home

 
   

 

 
 
Automobile Policy Change Request

Required Fields Are In Bold and  Marked With An *

     
Name of Insured *
Phone Number *
Email Address *
What Date Is This Change Effective? *
Is This A Change Of Address? * No Yes
If Yes, Please Supply New Address:
Is This A Change In Phone Number? * No Yes
If Yes, Please Supply New Phone Number:
Do You Want To Add A Driver? (If No, Please Skip To Next Section) * No Yes
Name of Driver Being Added:
Relationship To Insured
Driver's Permit/License Number
Date Of Birth
Does He/She Have A Defensive Driving Certificate?
Does He/She Have A Driver's Education Certificate?
Social Security Number For Added Driver
Do You Want To Delete A Driver? (If No, Please Skip To Next Section) * No Yes
Name Of Driver To Be Deleted
Reason For Deleting Driver (Will Require Contact From Agency Before It Can Be Processed)
Do You Want To Add A Vehicle? (If No, Please Skip To Next Section) * No Yes
Year Of Vehicle Added:
Make Of Vehicle Added:
Model Of Vehicle Added:
VIN For Vehicle Added:
Does It Have Anti-Lock Brakes?
How Many Airbags?
Does It Have An Anti-Theft Device Installed?
How Will Vehicle Be Driven?
Do You Want To Delete A Vehicle? (If No, Please Proceed To End) * No Yes
In Order To Delete A Vehicle, We Will Need The FS-6T From DMV Showing That You Turned In Your Plates. Do You Have This Form?
Year Of Vehicle Being Deleted:
Make Of Vehicle Being Deleted:
Model Of Vehicle Being Deleted:
VIN Of Vehicle Being Deleted:
Please Note That We Will Not Delete A Vehicle Until We Have The FS-6T, And That The Effective Date Will Be The Date That You Turned In The Plates. How Will You Be Supplying Us With The FS-6T?
Verification:

 

 

   
©2004 The Paul F. Tilly Agency, LLC
All rights reserved. No reproduction, distribution, or transmission of the copyrighted materials at this site is permitted.