Change Request Form Fleet Risk Management, Inc. PO Box 21860 St. Simons Island, GA 31522 (P) 866-638-8277 (F) 912-638-6577 (E)CustomerService@FleetRiskMGT.comCompany Name:*Change Eff. Date:* MM slash DD slash YYYY Driver ChangeLast NameFirst NameDOBDate of HireLicense NumberStateAddDeleteCDL Year of Exp. Equipment Change:(for Trailers, please specify if Dry Van, Reefer, Flat Bed, etc. in the TYPE field)YearMake17 Digit VIN NumberValueCo. OwnedOwner Oper.AddDeleteType NOYES For an equipment change that is Owner Operated, please also include the following:NameStreet AddressCityStateZip Code Additional Interest:(ex. Loss Payee, Additional Insured, Lien Holder, Leasing Agent)NameStreet AddressCityStateZip CodeInterest Type Notes:Signature:*Date:* MM slash DD slash YYYY CAPTCHA Δ