Schield Leavitt - Request Driver Change

Policyholder name:
Name of Individual requesting change:
Email:
Add:
Name as it appears on the license
Date of Birth
License #
State licensed in
Vehicle they drive most:
Delete:
Name of driver:
Name of person to contact if we have any questions:
Contact Phone Number

I understand that completing and sending this form does not bind coverage changes.
Please note this is an alternative method for communicating with us. We will contact you as soon as possible.