Change of Vehicle Request Form Page

Change of Vehicle Request Independent Distributor Insurance Program

  • Street Address
  • Address Line 2
  • City
  • State
  • Zip Code
  • THIS FORM WILL AUTHORIZE THE DSD INSURANCE AGENCY TO CHANGE THE INSURANCE COVERAGE AS INDICATED ABOVE. COVERAGE OPTIONS WILL REMAIN THE SAME.

  • Date Format: MM slash DD slash YYYY
  • :
  • Such insurance as may be bound: 1. Is afforded in reliance by DSD INSURANCE on the statements made by the Applicant. 2. Shall be effective on the date and time stated, but in no event sooner than such date and time. 3. Is subject to the terms, exclusions and conditions of applicable Insurance Company policy form, approved for use with respect to the classification of the Applicant. 4. Is limited to thirty (30) days from the effective date and time indicated above, unless canceled sooner by mailed written notice from Insurance Company to the Applicant at the address stated.

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DSD Insurance
135 Hayesbury Drive
Pelham, AL 35124
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(866) 621-1770