AUTOMOBILE POLICY CHANGE REQUEST

Instruction: Use this form if you need to add a new vehicle or delete a vehicle from your automobile policy.  Once the form is submitted, it will send the information you enter to RMD for processing.  If you have any questions or problems, please contact RMD customer services at 360.902.7303.

  • Fields in Blue are required on both ADD and DELETE request types

  • Fields in Green are required on ADD only

  • Fields in Brown are optional  

  • If you want to Delete a vehicle, you only need to fill out the Agency Information section, the Year, Make, Model and the Vehicle Identification Number (VIN).

Request type:       

ADD       DELETE   

 Agency Information:

Agency:
Effective Date:
Requestor:
Phone:
Email:
  Vehicle Information:
Year:
Make:       Model:
Identification # (VIN):
Type (Van, Bus, etc):     #of passenger seats:
Value of Vehicle:

Deductible:   

Comprehensive: 
Collision:

$
$
  Use & Trip Information:
Purpose & Use:
Radius of Operation: 
(in mile)
City where vehicle garaged:
Comments/Additional Information: