AG Direct Hail Insurance

AG Direct Hail Insurance

Policy Change Request
Misdescription or Error on Policy
If a policyholder has made an error in the description of the land location, type of crop, or name of the insured or payable to, AG Direct Hail Insurance requires the policy owner to complete the form below and submit the corrections for review.

If the policy change results in an increase in premium, the policyholder agrees to pay the additional premium. Conversely, if the change is accepted by AG Direct Hail Insurance and it results in a lower premium, the policyholder will receive a refund for the difference.

Please be advised that any change you are requesting to your policy will not be in effect until you have been contacted by an AG Direct Hail Insurance representative to finalize and confirm the changes.

All policy change requests are subject to approval.
Policyholder Name*

First NameLast Name
Policy Number
10 digit policy number starting with A24, S24, M24
Phone Number*
Please enter a valid phone number.
Today's date:*

MonthDayYear
Date
Please specify the type of change required.*

Policyholder Name - add/changeCompany Name - add/changeEmail address - add/changeMailing address - add/changePhone Number - add/changeCrop detail change (crop type or location corrections)Policy cancellation requestOther
"New" Policyholder Name*

First NameLast Name
"New" Company Name*
"New" Phone Number*
Please enter a valid phone number.
"New" Email*
example@example.com
"New" Address - Please ensure all fields are entered*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Other (Please specify the required policy change or reason for cancellation): *

Current Crop description*

Rows	Item #	Acres	Crop	QTR	SEC	TWN	RGE	MER
Crop detail
Crop detail
Crop detail
Crop detail

*Requested* New Crop description (Reminder: total acres cannot be increased on this change form. A new policy will be created for additional acres.) *

Rows	Item #	Acres	Crop	QTR	SEC	TWN	RGE	MER
NEW Crop detail
NEW Crop detail
NEW Crop detail
NEW Crop detail

I hereby request the above changes and accept and agree to pay any additional fees (if any). I understand that any change requested to my policy will not be in effect until I have been contacted by an AG Direct Hail Insurance representative to finalize and confirm the changes. All policy change requests are subject to approval.
Policyholder Name*

First NameLast Name
Signature*

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Misdescription or Error on Policy