Auto Policy Endorsement Request Form

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AUTO POLICY ENDORSEMENT REQUEST FORM

Insurance Form

Individual/salesperson and individual's name:

Effective date:

Vehicle traded in?:

Year, Make, Model, and VIN of new:

Titleholder:

Lien or lease with:

Email/fax proof to:

If insured is there...

Comprehensive deductible:

Full Glass:

Regular or Broad Collision and deductible:

Towing:

Rental Reimbursement:

Loan or lease gap (new vehicles only):

Who will drive vehicle:

Business use?:

Accessories or modifications:

Notes:

RGC User Email:

*Please remember, each line requires a response.

**Please also note, you must immediately copy/paste note into log- submissions are not stored.

PO Box 605
Roscommon 48653

2411 I75 BL Grayling MI 49738

400 N 5th St Roscommon MI 48653

297 Main St Coopersville MI 49404

Roscommon Phone: 989-275-5555
Grayling Phone: 989-348-4444
Coopersville Phone: 616-850-1111

Fax: 616-223-6996

Emergency: 989-889-1009

Monday - Friday
8:30 - 5:00
(Phones open at 9am)

Coverage, Price & Service: Your Needs, Our Mission