T5 INSURANCE SERVICESCUSTOMER SERVICE CENTER NO MATTER WHAT YOU NEED, WE'RE HERE TO HELP Customer Service Form What is the nature of your service request?* Vehicle Change ID Card Request Mortgage Change Submit a Claim Driver Change General Question I am a:* T5 Insurance Client Auto Dealer T5 Insurance Team (Internal) What date do you need this policy change/request to take effect?* MM slash DD slash YYYY Client Name:* First Last Client Email:* Client Cell Phone Number:*Date of Loss* MM slash DD slash YYYY Type of Loss*Auto AccidentFireWaterTheftLiabilityOther (provide details in loss description)Full Property Address* Street Address City State / Province / Region ZIP / Postal Code Where the claim occurredWas any Repair or Clean-Up Company called?* Yes No If yes, which company? Loss Description*The more detail you can provide the better we can assist you. Are you adding or removing a driver?* Adding Removing Drivers full name you'd like to remove* First Last Why are you removing this driver from your policy?* They moved out of my home They obtained their own auto policy They moved out of home and obtained their own auto policy Other reason Detailed reason why you are removing them from your policy?* Which vehicle do you need an ID card for (please enter year, make, and model)?*YearMakeModel Year, Make, and Model of New Vehicle*YearMakeModel Vehicle Identification Number (VIN):* Will you be getting new plates or transferring them from another vehicle?* New Plates Transferring Plates Which vehicle will we be removing?*YearMakeModel Will new vehicle be a lease or loan?* Lease Loan No loan or lease Name and full address of lease/loan company:Adding a mortgage or replacing current:*AddingReplacingMortgage company name:* Mortgage company address:* Street Address City State / Province / Region ZIP / Postal Code Where to send updated proof of insurance to:* New Driver Name* First Middle Last Date of birth* MM slash DD slash YYYY Driver's license number* State licensed* Relationship to you* Spouse Child Parent Other relation Does Dealer Need ID Card & Binder?* ID Card Binder Dealer Name:* Dealership calling from:* Dealer Phone# & Email Address:* If you are working with a auto dealer, please give us their contact information below. Any additional details or comments regarding this request:
