State-Owned Motor Vehicle Insurance Changes
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2STATE-OWNED MOTOR VEHICLE INSURANCE CHANGES
Please supply COMPLETE information. Changes are prorated and billed/credited at the end of the fiscal
year. When adding vehicles, this form should be submitted AFTER you obtain the license plate. You
have a 30-day grace period from the time you take possession to insure the vehicle. You will receive an
email as confirmation when information has been entered into the system.
Incomplete forms will be
returned to you for
completion.
NOTE: Please do not notify Risk Management of your auto insurance needs.
The AG's Office shares this information with Risk Management.
TYPE OR PRINT CLEARLY
Department _____________________________Division/Agency ___________________________________
Agency Contact Person _________________________________ Phone # _______________________
Fax # _________________________
Vehicle 1
Vehicle 2
Add
Delete
Edit (mark change)
Add
Delete
Edit (mark change)
Budget Account & Category ________________
Budget Account & Category ________________
Effective Date (Added or Deleted) _____________
Effective Date (Added or Deleted) _____________
Year ______ Make (e.g., FORD) ______________
Year ______ Make (e.g., FORD) ______________
Model (F150/F250)_________________________
Model (F150/F250)_________________________
VIN _____________________________________
VIN _____________________________________
VEHICLE CLASSIFICATION CODE____________
VEHICLE CLASSIFICATION CODE___________
Lic. #____________ Coverage
Lic. #____________ Coverage
N/A
N/A
L - Liability (mandatory)
L - Liability (mandatory)
CC - Comprehensive & Collision (optional)
CC - Comprehensive & Collision (optional)
Vehicle 4
Vehicle 3
Add
Delete
Edit (mark change)
Add
Delete
Edit (mark change)
Budget Account & Category ________________
Budget Account & Category ________________
Effective Date (Added or Deleted) _____________
Effective Date (Added or Deleted) _____________
Year ______ Make (e.g., FORD) ______________
Year ______ Make (e.g., FORD) ______________
Model (F150/F250)_________________________
Model (F150/F250)_________________________
VIN ____________________________________
VIN ____________________________________
VEHICLE CLASSIFICATION CODE____________
VEHICLE CLASSIFICATION CODE____________
Lic. #____________ Coverage
Lic. #____________ Coverage
N/A
N/A
L - Liability (mandatory)
L - Liability (mandatory)
CC - Comprehensive & Collision (optional)
CC - Comprehensive & Collision (optional)
Rev. 11/15
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