LOCAL GOVERNMENT INSURANCE TRUST

AUTOMOBILE and MOBILE EQUIPMENT CHANGE FORM
															
TO:		Scott Soderstrom, Underwriting Mgr.		(A-K)							VEHICLE CODES
		Ellen Nudd, Underwriter			(L-Z)				PP	-	Passenger Police		HTT	-	Tractor/Trailer											PF	-	Passenger Fire		HTR	-	Heavy Refuse	
									PO	-	Passenger/Other		HTD	-	Heavy Dump										LTPU	-	Light Pickup		HTF	-	Fire Truck										LTV	-	Vans		HTO	-	Heavy/Other										LTA	- 	Ambulance		BU	-	Bus under 15 Pass.										LTF	-	Fire/Rescue Truck		BO	-	Bus over 15 Passengers
MEMBER:										LTO	-	Light Truck/Other		TU	-	Trailer under 2,000 lbs
		 								ME	-	Mobile Equipment		T2	-	Trailer over 2,000 lbs. 
DATE:															

EFFECTIVE
DATE	DEPARTMENT	YEAR, MAKE, MODEL / DESCRIPTION	VIN / SERIAL NUMBER	(1)
VEHICLE CODE	(2)
VALUE
(ME only)	(3)
TAG#	(4)
TITLE#	AUTO LIABILITY

Yes or No	COMP / COLLISION

Yes or No	ADD /
DELETE
DATE	

											

											

											
											
(1)	Mobile equipment includes only self-propelled items to be scheduled
(2)	Mobile equipment less than 5 years use Replacement Cost (i.e., new); 5 and older use Actual Cash Value (i.e., “as is” includes depreciation)
(3)	Tagged vehicles require auto liability insurance.	
(4)  Tag and Title numbers are required for liability coverage.	
Page ___ of ___	Prepared By:____________________________________________________________