Service Request

Simply complete our service request form with the required information and we will get started ASAP!

Name(Required)

First Last

Email(Required)

Phone(Required)

Nearest Office Location(Required)

Which Policy Do You Need To Service?(Required)

What Other Type of Insurance?(Required)

Please Select The Home Changes You Need To Make(Required)

Change Mortgage Company

Add Personal Property Coverage

Change Your Mailing Address

File A Claim

Document Request

Billing Inquiry

Other

Please Select The Auto Changes You Need To Make(Required)

Add/Remove/Replace A Car

Add/Remove Driver

Add/Remove/Update Lienholder

Update Your Address

File A Claim

Billing Inquiry

Document Request

Other

Mortgage Company Name(Required)

Loan Number(Required)

New Mortgage Company(Required)

Street Address Address Line 2 City State ZIP Code

Mortgagee Clause

Personal Property Coverage

What type of personal property coverage change would you like to make?

How much more personal property coverage would you like to add?

Please list the specific items that should be added to your policy

Item Description

Replacement Value

Date Purchased

More Details

New Mailing Address(Required)

Street Address Address Line 2 City State ZIP Code

Why are you updating your address?(Required)

Update Address(Required)

Street Address Address Line 2 City State ZIP Code

Why are you updating your address?(Required)

Other Changes

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

Vehicle Changes

Which action are you requesting?

Vehicle to Remove

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

Reason For Removal?

What day did you stop owning the vehicle?

MM slash DD slash YYYY

Vehicle to Add

What Is The 17 Character VIN# Of Your New Car?

Please double check your entry to make sure it’s correct. Also note VINs never contain the letters L or O (if you see them they are 1 or 0).

How Will The New Car Be Used?

How Many Miles Will This Car Be Driven Annually?

The average commuter will drive approximately 13,000 miles a year.

What Is The Odometer Of Your New Car?

What Date Did You Purchase The Vehicle?

MM slash DD slash YYYY

Is their a lienholder?

Lienholder Name

If none, enter “none”

Lienholder Address

Street Address Address Line 2 City State ZIP Code

Who Is The Primary Driver?

New Vehicle Deductibles

What Comprehensive Deductible Would You Like?

Comprehensive covers everything other than an at fault accident. Ex. Theft, vandalism, a rock cracking your windshield on the freeway, etc.

What Collision Deductible Would You Like?

NOTE: The lower the deductible, the higher the premium.

Add/Remove Driver Information

Which driver action are you requesting?

New Driver Information

New Driver Full Name(Required)

New Driver Date of Birth(Required)

MM slash DD slash YYYY

New Driver DL#(Required)

New Driver's Relation To You

Other Relation

Does new driver live with you?

New Driver's Employer or School

Current High School Student With A 3.0 or Better GPA

If the new driver is a high school student with a 3.0 or better GPA, they may qualify for a “good student discount”. You will need to submit proof (last report card).

New Driver's Address

Street Address Address Line 2 City State ZIP Code

Removed Driver Information

Name(Required)

First Last

Date of Birth(Required)

MM slash DD slash YYYY

Reason For Removing Driver

Is This Person Still A Household Resident?

Document Request

Which Document(s) Are You Requesting?(Required)

When Do You Need The Document(s)?(Required)

MM slash DD slash YYYY

File

Max. file size: 39 MB.

More Details

How would you like your document delivered?(Required)

If you need your documents urgently please click the link below and navigate to your insurance carrier’s website or service phone number.
If this is not a time-sensitive request our team will have your documents emailed to you in less than 24 business hours.

Lienholder Information

What type of lienholder change are you requesting?(Required)

Add Lienholder

Remove Lienholder

Update Lienholder

Vehicle Year/Make/Model(Required)

Lienholder Name

Lienholder Address

Street Address Address Line 2 City State ZIP Code

Other Change Details

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

Business Policy Changes

What type of commercial property coverage change would you like to make?

How much more commercial property coverage would you like to add?

Please list the specific items that should be added to your policy

Item Description

Replacement Value

Date Purchased

Business Name(Required)

Business Policy(ies) Needing Service

Business Auto/Fleet

Business Property

General Liability

Workers Comp

Commercial Package

Other

Other Type of Policy(Required)

Do you need to file a claim or request a COI?

File A Claim

Request A COI

Other Type of Change

Cert Holder Name(Required)

First Last

Email you want COI SENT TO(Required)

Cert Holder Address(Required)

Street Address Address Line 2 City State ZIP Code

Please explain the details of your change reqeust.(Required)

Business Auto

What action are you requesting?

Vehicle to Remove

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

Reason For Removal?

What day did you stop owning the vehicle?

MM slash DD slash YYYY

Vehicle to Add

What Is The 17 Character VIN# Of Your New Car?

Please double check your entry to make sure it’s correct. Also note VINs never contain the letters L or O (if you see them they are 1 or 0).

How Will The New Car Be Used?

How Many Miles Will This Car Be Driven Annually?

The average commuter will drive approximately 13,000 miles a year.

What Is The Odometer Of Your New Car?

What Date Did You Purchase The Vehicle?

MM slash DD slash YYYY

Does Your New Car Need Comprehensive & Collision Coverage?(Required)

Is there a lienholder?

Lienholder Name(Required)

If none, enter “none”

Lienholder Address(Required)

Street Address Address Line 2 City State ZIP Code

Who Is The Primary Driver?

What Comprehensive Deductible Would You Like?

Comprehensive covers everything other than an at fault accident. Ex. Theft, vandalism, a rock cracking your windshield on the freeway, etc.

What Collision Deductible Would You Like?

NOTE: The lower the deductible, the higher the premium.

Update Drivers

What type of driver update

Add driver

Remove driver

New Driver Information

New Driver Name(Required)

First Last

New Driver Date of Birth(Required)

MM slash DD slash YYYY

New Driver DL#(Required)

New Driver's Address(Required)

Street Address Address Line 2 City State ZIP Code

Removed Driver Information

Name(Required)

First Last

Date of Birth(Required)

MM slash DD slash YYYY

Reason For Removing Driver

Claim Information

Date of Loss

MM slash DD slash YYYY

Please list details of the claim here we will reach out to you as soon as possible.(Required)

Consent(Required)

I understand that the purpose of completing this form is to inform Eclipse Insurance Agency about a claim i would like to file. I also understand that completing this form does not constitute filing a claim with my insurance carrier.

Eclipse Insurance Agency will use this information to evalute my claim and advise me about filing a claim.

Billing Inquiry

Please tell us about your billing inquiry.(Required)

Details of request

Please upload any files pertaining to your request.

Max. file size: 39 MB.

Agreement(Required)

I understand that submitting this form does not actually make any changes to my policy. This form is only a request and no changes to my policy are effective until I receive confirmation from Eclipse Insurance Agency.

CAPTCHA

Simply complete our service request form with the required information and we will get started ASAP!

Personal Property Coverage

Other Changes

Vehicle Changes

Vehicle to Remove

Vehicle to Add

New Vehicle Deductibles

Add/Remove Driver Information

New Driver Information

Removed Driver Information

Document Request

Lienholder Information

Other Change Details

Business Policy Changes

Business Auto

Vehicle to Remove

Vehicle to Add

Update Drivers

New Driver Information

Removed Driver Information

Claim Information

Billing Inquiry

Request Your Proposal Here