Your First Name:                           
(This form is for current customers only)

Your Last Name:                     

Your E-Mail Address:               

GENERAL CHANGES

Change    Correct    My Mailing Address                            

Change    Correct    My Phone # 

Add    Delete    Change    
My E-Mail Address 

Add    Delete    Change    
My Car Phone #  

ADD A VEHICLE             

Year  Make Model   

ID# (required)
Please call the Dealer, I don't have the ID #  

The Dealer's Name and City
                                                            

Would you like for us to fax information to the Court House so 
you can get your tag?         

 If so, which County?
(Allow a couple of days)

The Primary Driver for the vehicle above is:

Please add the following coverage:

Liability Only (No Comp, No Collision)   
Liability and Comp (No Collision)           
Liability, Comp & Collision                                                 

Lien Holder's Name & City    

Please call the Dealer, I don't have this information     

The Dealer's Name and City  

If this is a replacement vehicle, show which vehicle you want
to delete below.

Go to the bottom of screen to submit changes*****

DELETE A VEHICLE  

Year   Make   Model

ID# (not required)

DELETE A LIEN HOLDER

Which Lien Holder?    
From Which Vehicle? 
Do You Wish to Delete Collision (keep liability & comp)? 
No    Yes
Do You Wish to Delete Comp & Collision (keep liability only)? 
No    Yes

Go to the bottom of screen to submit changes*****

ADD A DRIVER                                   

First Name:  Last Name:

Male        Female

Date of Birth   Drivers License #         
Social Security #   

Type of License:        Learners Permit:      
Learners Permit with Farm Exemption       
Restricted                                               
Regular License                                                                                       

The Driver above primarily drives the following vehicle:
Year  Make:   Model:

The Driver above does not does not sure qualify for a "Good Student Discount".

Good Student Discounts are available for Allied Customers @ 
age 15 and 16 for all other companies.
Rank among the upper 20% of the class scholastically:        
For letter grades, a "B" average:                                          
At least a 3.0 average on a 4.0 scale:                                  
Included on the "Dean's List" or "Honor Roll":                        
Note: We will send a form to the school for a school official's signature.

My Student is a:    Freshman Sophomore Junior Senior  
Which School?             
Which City?         

Go to the bottom of screen to submit changes*****

REPORTING GLASS CLAIMS
(GLASS ONLY) 

Vehicle #1: I need to have my windshield repaired replaced not sure    
On the following Vehicle: 

Vehicle #2: I need to have my windshield repaired replaced not sure    
On the following Vehicle:

Vehicle #3: I need to have my windshield repaired replaced not sure    
On the following Vehicle:

If you are note sure you've got Comp Coverage, or wish to inquire 
about your Deductible, please call us @ 888-525-2240. 

GLASS COMPANIES        

Choose one of the Glass Businesses below, or one of your own, 
and have them send us the bill. Your Deductible will be collected 
by the Glass Company after the work is done.

Below is a list of some of the Glass Companies we use.

Speedy Mobile Glass    Sante Fe Trail Glass     Kansas Mobile Glass
800-851-8952                800-794-8657               800-456-1309
Repair or Replace       Repair or Replace      Repair or Replace
Jetmore                        Dodge City                   Hays
                                                                    

Safelite Mobile Glass     Novus                          Hilly's
800-432-0169                800-776-6887                316-285-2245
Repair or Replace       Repair Only                 Repair Only                         
Hays                                                                Larned

Go to the bottom of screen to submit changes*****

 
OTHER AUTO CHANGES

Go to the bottom of screen to submit changes*****

HOMEOWNERS CHANGE
                                                    

Add        Delete        Change      1st  Mortgagee:

Add        Delete        Change      2nd Mortgagee:

Other Home Changes

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