Leavitt Insurance Agency - Request Driver Change

Request Driver Change

Policyholder name:
Contact Name:	*
Contact Phone:	*
Email:	*
Add:
Name as it appears on the license
Date of Birth
License #
State licensed in
Vehicle they drive most:
Delete:
Name of driver:

I understand that completing and sending this form does not bind coverage changes, and that no such changes will be in effect unless, and until, I receive written confirmation of the changes from my insurance agent.
Please note this is an alternative method for communicating with us. We will contact you as soon as possible.