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 Date Claim Reported MM slash DD slash YYYY Client Name:* First Last Client Email:* Client Cell Phone Number:*Preferred Contact Method For ClaimPhoneEmailDate of Loss* MM slash DD slash YYYY Time Of Loss : Hours Minutes AM PM AM/PM 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?Location of the accidentLoss Description, What Happen?*The more detail you can provide the better we can assist you. Any Witnesses? Name & Contact InfoT5 Insured Driver NameT5 Insured Vehicle InvolvedT5 Party Injured?Is the T5 vehicle driveable?* Yes No Police Report Completed? Yes No Which Police Agency Reported?Other Parties Information (Name of driver, contact info, vehicle year make model, insurance information, other passengers,?Other Party Injuries?Any photos or police report being sent in?Clients immediate needs to follow up on? Rental Vehicle, Lodging assistance etcDrivers 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 Is this new vehicle: Brand new Used Vehicle 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:*AddingReplacingWhich position are they look to be added?First PositionSecond PositionMortgage company name:*Mortgage company address:* Street Address City State / Province / Region ZIP / Postal Code Loan Number If Needed?Where to send updated proof of insurance to: (Email)*Name & Phone Number of who is calling in or entering request.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: (Reminder to Dealer our office needs MSO & Bill of sale emailed to service@t5insurance.com)*If you are working with a auto dealer, please give us their contact information below.Any additional details or comments regarding this request:
