Vehicle Change Request Form

Producer Name: Pacific Preferred Insurance
California License No. 0H55899
Address: 2775 N Ventura Road, Suite 110, Oxnard, CA 93036
Phone: 800-913-1844 Email: lowcostauto@pacificinsuresme.com

Do you still own or have possession of the vehicle you insured through the California Low Cost Auto Insurance Program?*

YesNo

Is the currently insured vehicle a Planned Nonoperation (PNO) vehicle? (The vehicle will not be driven, towed, stored, or parked on public roads or highways for the entire registration year.)*

YesNo

NOTE: The California Low Cost Auto Insurance Program requires that you insure all eligible vehicles through the Program. Therefore, if you were to still own or have possession of a vehicle currenlty insured through the Program, you'd have to apply for a second policy. You're allow up to two policies per household member.

To apply for a second vehicle, please visit mylowcostauto.com or contact our office directly at please contact our office at 1-800-913-1844 or via email at lowcostauto@pacificinsuresme.com.

First Name*

Last Name*

Date of Birth*

MonthDayYear

Email of Insured*

example@example.com

Phone Number*

Please enter a valid phone number.

Is this the email and/or phone number we currently have on file?*

YesNo

Old Email

example@example.com

Old Phone Number

Please enter a valid phone number.

Mailing Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Is this the mailing address we have on file?*

YesNo

Previous Address:*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Is your mailing address the same as your physical address?*

YesNo

Physical Address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Please select your current insurance provider:*

Integon National21st Century CentennialCAARP/AIOUnknown

NCIS Number

Policy Number*

Please locate the number on your policy and NOT your previously issued temporary insurance card.

Is this a change you would like have made immediately? (Please note, changes can take up to 5 business days.)*

YesNo

What date would you like this change to take place? *

Date must be in the future - there is no backdating allowed. Soonest Date Accepted is Date Following Submission.

Why are your replacing your curently insured vehicle?*

Vehicle was soldVehicle was traded inIt is planned for nonoperation (PNO)Other

What is the currently insured vehicle that you are replacing? *

What is the make & model of your new vehicle?*

What year is your new vehicle? *

1981 and Newer - What is the new vehicle's identification number (VIN)? *

Model year 1981 to present have 17 characters

1980 and Older: What is the new vehicle's identification number (VIN)? *

What is the new vehicle's current value?*

If determined to be over $25,000 and/or leased, then this change form will not be processed and rather rejected.

What is the new vehicle's primary use?*

PleasureCommuting To Work/To SchoolBusinessFarm

Is your name on the registrtion or title of the new vehicle?*

YesNo

Is there anyone else listed on the registration/title?

YesNo

What is your relationship with the registered owner?

Would you like to extend coverage for this vehicle to your spouse?

YesNo

Please provide the name of the registered owner:

First NameLast Name

NEED TEXT HERE

Explanation about extending coverage to spouse.

Please upload a copy of your new vehicle registration, title, or sales contract:*

Terms of Use for Submission of Change Form

By submitting this change form and signing below, you confirm that the information provided is accurate to the best of your knowledge. Our agency is not liable for forms not processed by us or the insurance company, and it is your responsibility to follow up if confirmation is not received within 30 days.

We are not responsible for submission errors, including technical issues that may prevent delivery. You must verify successful submission. Submission of this form does not confirm policy status, and if the insurance company deems your policy inactive at the time of submission, the request will be void. The effective date of any changes will be the day following successful submission to the insurance company, or a future date as indicated on the form. Backdating is not permitted.

If the information provided does not match our records or if we cannot locate your account, this request may be disregarded. Please ensure all information is accurate.

Hold Harmless and Release of Liability

By submitting this form, you release and hold harmless our agency, its officers, agents, employees, and affiliates from any liability, claims, or actions arising from the use or submission of this change form, including issues related to processing, delivery, or acceptance by the insurance company. You acknowledge responsibility for accurate information and for following up if confirmation is not received within the specified time frame.

You understand that the California Low Cost Auto Insurance Program offers liability-only coverage and does not include physical damage or theft coverage (Collision or Comprehensive). If you have a lienholder, additional coverage may be required, and failure to secure it could lead to repossession or forced insurance by the lienholder. By submitting this form, you certify responsibility for obtaining any additional coverage as needed.

INSURED CERTIFICATION SECTION

I, the named insured of the above policy, under penalty of perjury, hereby certify to the best of my knowledge that:

I continue to meet the eligibility requirements for the California Low Cost Automobile Insurance Program.

ANY PERSON WHO KNOWINGLY MAKES AN APPLICATION FOR MOTOR VEHICLE INSURANCE COVERAGE CONTAINING ANY STATEMENT THAT THE APPLICANT RESIDES OR IS DOMICILED IN THIS STATE AND IN THE COUNTY SHOWN ON THE APPLICATION WHEN, IN FACT, THE APPLICANT RESIDES OR IS DOMICILED IN ANOTHER STATE OR IN ANOTHER COUNTY OF THIS STATE, IS SUBJECT TO CRIMINAL AND CIVIL PENAL TIES.

FOR YOUR PROTECTION CALIFORNIA LAW REQUIRES THE FOLLOWING TO APPEAR ON THIS FORM.

ANY PERSON WHO KNOWINGLY PRESENTS FALSE OR FRAUDULENT INFORMATION TO OBTAIN OR AMEND INSURANCE COVERAGE OR TO MAKE A CLAIM FOR THE PAYMENT OF A LOSS IS GUILTY OF A CRIME AND MAY BE SUBJECT TO FINES AND CONFINEMENT IN STATE PRISON.

Acknowledged and Agreed to by:*

Applicant Signature

Applicant's Name:*

First NameLast Name

Date Signed:*

MonthDayYear

Approver Email

example@example.com

Approver Decision

Additional Info for Customer:

Explain in detail the reasons for denial or the additional informatoin that is needed.

Approver Edit?

Email Trigger Final

Approval Status

Vehicle Change Request Form

Personal Information

Vehicle & Insurance Information