Personal Lines Form

Personal Lines Form
Date of Request

MonthDayYear
Hit F5 to update date and time.
AM/PM Option
Agent making request*
Who/How request was made?
Name*

First NameLast Name
Customer name
Customer Number*
Effective Date

MonthDayYear
Date
Please select all that apply

Cancellation / ReinstatmentPolicy ChangeGeneral Inquiry/NoteQuote Only
Type of Request

AutoHomeMotorcycle/ATV/Snowmobile/BoatMotorhomeUpdate Mailing Address
Cancellation / Reinstatement

Non-PayPayment MadeSigned LPR
Amount due:
Notes:
Auto Change Request
Type of change being requested (choose all that apply)

Add a vehicleRemove a vehicleEdit coverageAdd operatorRemove operatorEdit loss payee
Remove a vehicle
Which vehicle is being removed?
Add a vehicle
Nature of business
Is a pickup being added?

YesNo
ID Card
Lienholder
Name of new loss payee / lessor
Email - For EPI
example@example.com
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Fax Number
Please enter a valid phone number.
Name of new loss payee / lessor
Email - For EPI (vehicle 2)
example@example.com
Address (vehicle 2)

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Fax Number(vehicle 2)
Please enter a valid phone number.
Coverage Change
Any other changes being requested?
Add a driver
Remove a driver
Who is being removed?
Edit Loss Payee
Type of change being made? (choose all that apply)

Add loss payeeDelete loss payee
Name of loss payee being removed
Why?
Motorhome Change Request
Adding or removing motorhome?

AddRemove
If more than one, which one being removed?
Add Motorhome
Homeowners Change Request
Coverage Change
Deductible Change
Requested Change

Change CoverageChange DeductibleMortgagee / InterestAdd or Remove Broadening CoverageAdd or Remove Scheduled Item(s)EPI RequestRequest to Add New Building or Location
Mortgagee / Interest Change
Type of change being made? (choose all that apply)

Add / UpdateDelete
Name of interest being removed
Why?
Add / Remove Broadening Coverage
Explain Change
If removing - Obtained Signed PCR?

YesNo
Add / Remove Scheduled Item(s)
Explain Change
Was appraisal obtained?
EPI Request
Where does the EPI need to be sent?
Email
example@example.com
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Fax Number
Please enter a valid phone number.
Add New Building or Location
Property Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Property Description
How close to water, if coastal?
If camp, is it accessible year round?
Deeded Owner?
Electrical Info
Plumbing Info
Heating Info
Woodstove Information
Roofing Information
Fire Dept Information
Motorcycle/ATV/Snowmobile/Boat
Type of change being requested (choose all that apply)

Add VehicleRemove VehicleAdd OperatorRemove Operater
What is being removed?
New Vehicle Info
Driver of Vehicle
If driver not listed, obtain Name, DOB, License, Marital Status
Will there be any unlisted drivers who may operate?
If yes, get their information
Is there a Leinholder?

YesNo
Lienholder Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Email Address
example@example.com
Fax Number
Please enter a valid phone number.
Mailing Address Change

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Update Garaging Location?
Add Operator
Does Umbrella need to be endorsed?

YesNo
Remove Operator
Who is being removed?
Notes
General Inquiry / Notes:
Should be Empty:

Personal Lines Form

Auto Change Request

Remove a vehicle

Add a vehicle

Coverage Change

Add a driver

Remove a driver

Edit Loss Payee

Motorhome Change Request

Homeowners Change Request

Mortgagee / Interest Change

Add / Remove Broadening Coverage

Add / Remove Scheduled Item(s)

EPI Request

Add New Building or Location

Motorcycle/ATV/Snowmobile/Boat