Policy Service Request Form
Name Insured
*
First Name
Last Name
Email
*
example@example.com
Phone Number
*
Please enter a valid phone number.
What policy are you making a request for?
*
Personal
Commercial
Change Effective Date
*
-
Month
-
Day
Year
Date
What is the nature of your Personal Policy request?
*
Please Select
I need an ID Card for a vehicle
I need to add/remove a vehicle
I need to add/remove a driver
I need to add to my personal property coverage
I need documentation for a mortgage change request
I need to change my mailing address
I need proof of coverage
I need to change my payment method
I need to make a payment
I need to cancel a policy
I need to file a claim
Other
What is the nature of your Commercial Policy request?
*
Please Select
I need a certificate of insurance
I need to add an additional insured
I need to update revenue,employees, or payroll figures
I need to add or change coverage
I need to change payment method
I need to make a payment
I need to cancel a policy
I need to discuss a claim
Other
New Mailing Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Reason for Policy Cancellation Request
*
When is a good time to call you regarding your payment information?
*
-
Month
-
Day
Year
Date
Please describe your questions or issues regarding your claim
*
Please describe the nature of your request in as much detail as possible.
*
Vehicle Details
Are you adding or removing this vehicle?
*
Please Select
I am adding this vehicle
I am removing this vehicle
Who is the primary driver of this vehicle?
*
First Name
Last Name
Vehicle Year
Vehicle Make
*
Vehicle Model
*
Vehicle Identification Number
*
Vehicle Purchase Date
*
-
Month
-
Day
Year
Date
Vehicle Usage
*
Please Select
Pleasure Use
Work/School Commute
Business/Commercial/Rideshare
Is this car replacing a vehicle in your policy?
*
Yes
No
Replaced Vehicle Year
*
Replaced Vehicle Make
*
Replaced Vehicle Model
*
Replaced Vehicle Identification Number
*
Reason for removing this vehicle
*
Driver Details
Name of Driver
*
First Name
Last Name
Driver's Date of Birth
*
-
Month
-
Day
Year
Date
Driver's License Number
*
Driver's Relationship to You
*
Add or Remove this Driver?
*
Add
Remove
Will this driver operate any vehicle you own?
*
Yes
No
Is this driver a full-time student?
*
Yes
No
Vehicle Year
*
Vehicle Make
*
Vehicle Model
*
Reason for removing this driver
*
Item Detail
Item List
*
End of Form
Notes, Comments, or Questions related to this inquiry
Attach any additional documents here if available. For Certificate Requests, attach your contract if available
Browse Files
Drag and drop files here
Choose a file
Cancel
of
By signing below, I acknowledge that: (i) The above information provided to IIC Independence Insurance Center is true and correct, and (ii) if untruthful or inacurate, may result in an increase in premium, or rejection, cancellation, or rescission of my policy by the insurance company. I further understand that this document does not infer or bind coverage of any kind. My agent has fully explained and provided me with ample opportunity to ask any questions concerning all coverages, limits, and insurance companies avaiable.
*
Continue
Continue
Should be Empty: