Car Insurance Refund Form

Car Insurance Refund Form
In case you have/had a policy with us before August 2020, you may be eligible for a partial refund on insurance costs.
Please fill out the form below. Once submitted, we will process the request and we will get in touch with you through the phone number and/or email address that you will provide below:
Policy Information
Name of Policy Holder
Policy Number
Coverage
Commencement Date
MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Expiration Date
MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Vehicle Information
Vehicle Plate Number
Vehicle Make
Vehicle Model
Year Manufactured
Vehicle Registration Number
Mileage
Enter number of estimated miles you traveled with your vehicle during lockdown
Contact Information
Name
First NameLast Name
Address
Street Address
Street Address Line 2
CityState / Province
Postal / Zip Code
Email
example@example.com
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Reason for Refund Request
CONSENT
I confirm the information provided above is true and correct to the best of my knowledge. I further understand that any misrepresentations on this form may cause the denial or decline of my request.
Name
First NameLast Name
Signature
Clear
Date Signed
MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Should be Empty: