By entering the requested information we will be able to process and return your Auto Change Request. If you should have any questions regarding the completion of the form you may call us at 513.868.9000 or email Your request will be submitted and processed within 2 business days. You will be notified when the request has been completed.

General Information
  Your Name:  
  Phone Number:  
  Email Address:  
  What is the best way / time to contact you:

Vehicle Information
  Add or Delete:  
  Effective Date:  
      * vehicle identification number
  Check items that apply:   Alarm System Anti Lock Brakes  
      Driver's Side Air Bags Passenger Side Air Bags

Purchase / Lease Information
  Purchased or Leased:    
  Loan or Lease Company:  
  Is GAP coverage desired: Yes No

Driver Information
  Primary Driver Name:  
  Vehicle Usage:  
  Miles to Work (One Way):  
  Is this a new driver on this policy: Yes No
  If yes please provide:      
  Date of Birth:    
  Social Security Number:    
  Drivers License Number:    
  *Does Good Student Discount Apply:
      Yes No *Requires B Average or Better

  Anything else you would like to tell or ask us:
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As an independent insurance agency Wilks Insurance Agency have provided Greater Cincinnati residents with the best home and car insurance protection available.

319 N 2nd St Hamilton OH 45011 USA (513) 868-9000