Customer Service Request - Leal Insurance Services, LLC

Which Policy Do You Need To Service?*
- Auto Policy
- Home Policy
Policy Number(s):*

Please enter the policy number(s) that this change should apply to.

Please Select The Home Changes You Need To Make*
- Change Mortgage Company
- Add More Personal Property Coveage
- Change Your Mailing Address
- Other

New Mortgage Company*
Mortage Company Name and Street Address Loan Number City State ZIP Code

Please Specify The Items Needing Coverage And Their Individual Values

New Mailing Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Please Specify Your "Other" Changes. Be As Specific As Possible*

Please Select The Changes You Need To Make*
- Add Or Replace A Car
- Remove A Car
- Add A Driver
- Remove A Driver
- Add A Lienholder
- Change Your Mailing Address
- Other

Your Name*
First Last

Which Car Are You Removing? (Yr, Make, Model)*

Reason For Removal?*
- Sold
- Not Functional
- Totaled out
- Other

When Did You Get Rid Of The Car? (Specific Date)*

New Driver Full Name*
New Driver Date Of Birth
MM slash DD slash YYYY
New Driver DL#*
New Driver Relation To You*

Current High School Student With A 3.0 or Better GPA?*
- Yes
- No
If the new driver is a high school student with a 3.0 or better GPA, they will qualify for a "good student discount". You will need to submit proof (last report card) to info@lealinsurance.com

Name Of Driver You Are Removing?*

Is This Person Still A Household Resident?*
- Yes
- No

Bank Name*

Which Vehicle Is This For?*

New Mailing Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Please Specify Your "Other" Changes. Be As Specific As Possible*

Is This New Car Replacing Another Car?*
- Yes (Replace A Current Car With A Different Car)
- No (This Is New Car To Me)

Which Of Your Vehicles Are Re Replacing With The New Car? (Yr/Make Model?)*

How Will The New Car Be Used?*
- Pleasure
- Work/School Commute
- Business/Commercial

How Many Miles Will This Car Be Driven Annually?*

Texas DMV says the average commuter will drive approximately 15,000 miles a year.

Please list the Year/Make/Model/VIN for the new vehicle*

Please double check your entry to make sure it's correct.

What Was The Purchase Date?*

Coverage for the new vehicle*
- Liability ONLY
- Liability + Physical Damage (Bank required Comprehensive / Collision Coverage)

What Comprehensive Deductible Would You Like?*
- $100
- $250
- $500
- $1000
Comprehensive is defined as "all other than collision". Ex. Theft, vandalism, a rock cracking your windshield on the freeway, etc.
What Collision Deductible Would You Like?*
- $100
- $250
- $500
- $1000
NOTE: The lower the deductible, the higher the premium.

Is There A Lien Holder? If So, Who?*

If none, enter "none"

Who Is The Primary Driver?*

Cell Phone Number*
We Will Send A Text Confirmation That This Request Was Received
Email*

We will send confirmation when this request is processed along with any changes in billing for your reference.
I agree to the following:*
I affirm and agree to the following:
By submitting this request you are authorizing Leal Insurance Services, LLC, to submit this endorsement request to the appropriate carrier and any additional premium that may be due as a result of the change. You authorize Leal Insurance Services, LLC, its affiliates and carrier partners the access to pull the necessary reports (i.e. claims, credit, and loss history) to confirm the data submitted.

Submitting this endorsement request does not constitute a binding confirmation of a new or revised insurance coverage.

Usual processing time for endorsement confirmation if request is received during normal business is 1-2 hours. If request is received after-hours, the endorsement will processed next business within 1-2 hours of opening. If provided with incomplete information, the processing the endorsement may be delayed, in which case you will be notified.

Leal Insurance Services, LLC is committed to respecting your privacy and communication preferences. So that we may remain compliant with state and federal regulations, we need your expressed permission to communicate with you through phone, text and email as needed.

You may opt-out of all future communication at any time by making your preferences known to us.
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