Harbor Brenn Insurance Agency - Northern Michigan

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Auto Change Information Form

Auto Dealers: Please submit the following information for our mutual clients to secure the proof of insurance for their new vehicle. We will contact our insured to confirm coverage. Information marked with an asterisk (*) is required on this form and if the information requested does not apply just fill in "none" in that section.

Proof of insurance will be emailed or faxed to you upon receipt of this form. We will then contact the insured to confirm coverage and endorse their policy.
Please Note: if the client does not currently have a policy with us, they need to call and secure a quote and policy before we can provide proof of insurance.

Required *

Client's Name *

Please provide Client's first and last names

Client's Phone *

Please provide Client's phone number

Name as it appears on vehicle Title *

Please provide the name exactly as it appears on the vehicle title

Year *

Please provide the Year in which the vehicle was manufactured

Make *

Please provide the Make of the vehicle

Model *

Please provide the vehicle Model

VIN *

Please provide the vehicle VIN

Number and Type of Air Bags *

Please provide the Number and Type of Air Bags

Anti-Lock Brakes – 2 or 4 wheel * 2 wheel 4 wheel

Please designate whether Anti-Lock Brakes are 2 or 4 wheel

Type of Anti Theft Device *

Please indicate the type of Anti Theft Device on this vehicle

Hybrid or Electric Car * Neither Hybrid Electric

Please indicate whether this vehicle is a Hybrid or Electric car

Gap Coverage Included? * No Yes

Please indicate whether or not Gap Coverage is included

Lien or Lease Name *

Please provide the lienholder or lessor name

Lien or Lease Complete Address *

Please provide the full address of the lienholder/lessor

Vehicle Traded In? No Yes

Additional Comments/Notes

Dealer Name *

Please provide the dealer name

Dealer Phone *

Please provide the dealer phone number

Dealer Fax *

Please provide the dealer fax number

Dealer Email

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Harbor/Brenn Agencies

Petoskey Location [map]
1231 N US 31 HWY
Petoskey, Michigan 49770

Agency Phone Numbers

Phone (231) 347-8113
Fax (231) 347-3853
Toll Free (866) 347-8113

Harbor/Brenn Office Hours

Monday - Friday
9:00 a.m. to 5:00 p.m.
After Hours by Appointment

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