If you need to add/delete/change more than 1 driver, please complete the attached top section of this form and contact our office to process the rest of the list. You may always contact our customer service department for assistance with your request: Customer Service Department 877-424-3344 x 3 service@gainins.com Add DriverRemove DriverSwap Driver Company Information Representative First Name (required) Representative Last Name (required) Company Name (required) Address (required) City (required) State (required) Zipcode (required) Email (required) Phone Number(required) Policy Information Policy Number New Driver Information New Driver First Name New Driver Last Name New Driver License State New Driver DOB License Number Years of Experience Date of Hire Remove Driver Information Removing - Driver First Name Removing - Driver Last Name Removing - Driver License Number Date of Driver Removal Additional Notes on Request If you have any questions regarding your email please call our contact office directly Gain Insurance Agency 323-987-2333 x 1 Customer service service@gainins.com “Please keep in mind that this acknowledgment does not constitute acceptance of coverage, change, endorsement or an agreement to insure, and does not create any obligation of any kind, contractual or otherwise. Changes and payments to policies are not effective or binding until you, or any party involved, receive official acceptance notice from either your insurance agent, or your insurance company in writing via email.” As the Internet is not a fully secure environment, Gain Insurance Agency cannot ensure that this or any other email has not been interfered with during transmission. The sender, therefore, does not accept liability for any errors or omissions in the contents of this message that arise because of email transmission. Acknowledge