Hennessey, Thames, & Leavitt - Request Vehicle Change

Request Vehicle Change

Policyholder Name:
Name of individual requesting change:
Phone Number
Email address:

Vehicle Description
Year:
Make
Model
VIN/Serial #:

I understand that completing and sending this form does not bind coverage changes.
Please note this is an alternative method for communicating with us. We will contact you as soon as possible.

	July 29, 2010