Insurance Submission Form

Customer Name*
First Last
Account Number*
Insurance Company*
Insurance Agent
Insurance Contact Number
Policy / Binder Number*
Policy Term (months)
Please be advised that SAFCO requires a minimum 6 month policy. Contact your insurance company to update your policy.
Effective Date
Date Format: MM slash DD slash YYYY
Expiration Date
Date Format: MM slash DD slash YYYY
Comprehensive Deductible
Please enter a number from 0 to 10000.
Please be advised that SAFCO requires a maximum deductible of $1,000. Contact your insurance company to update your policy.
Collision Deductible
Please enter a number from 0 to 10000.
Please be advised that SAFCO requires a maximum deductible of $1,000. Contact your insurance company to update your policy.
Is SAFCO listed as the loss payee on my policy?
- Yes
- No
Please be advised that SAFCO must be listed as the loss payee or lienholder. Contact your insurance company to update your policy.
Upload Copy of your Insurance Policy
Accepted file types: pdf, doc, docx, jpg, gif, png.
You may also fax a copy of your insurance policy to 1-866-319-1597. Be sure to include your name and account number on the fax, and call back to confirm receipt at 1-800-998-0763.

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