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Request Vehicle Change

Modification Type
Effective Date
Policyholder Name:
Contact Name : *  
Phone Number *  
Email address: *  
Vehicle Description
Year:
Make
Model
VIN/Serial #:
   
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.

info-wdi@leavitt.com

816 5th Street
PO Box 1300
Rapid City, SD 57709
Phone: 605.342.3130

1001 Lazelle Ave
PO Box 490
Sturgis, SD 57785
Phone: 605.347.4583

2011 N. Main
PO Box 98
Spearfish, SD 57783
Phone: 605.642.2624

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