Change Request/Claims Form

Service/Change/Claims
Customer Info
Customer Name*

First NameLast Name
Cell Phone Number*
Please enter a valid phone number.
Customer confirmed texting?*

YesNo
Customer Email*
example@example.com
Policy Info
First Name on Policy
*If other then person calling in
Carrier Name*
If more then one carrier separate by comma
Policy Number*
If more then one policy number separate by comma
Policy Type*
If more then one policy type separate by comma
Agent Name*
CSR Name*
Email of CSR to receive a copy of the change request: *
Service Request Type
Service Request to be completed*
What is the date this change should take effect? What date did the claim occur? *

MonthDayYear
Date
Do you need to schedule a call back for the agent on this account?*

YesNo
Agent/CSR appointment setting process
1. Use the following info to complete scheduling link
  - Customer Name: {customerName}
  - Call Back Number: {cellPhone}
  - Call Details: {pleaseDescribe}{claimsDetails}
2. Use the Scheduling Links below
  - Agent Name 1: Click Here
  - Agent Name 2: Click Here
  - Agent Name 3: Click Here
    
    Calendly Example: Click Here
    
    **calendly will cost $120 per year per seat
Other Change Request
Please describe the change request below:
File Upload

Cancelof
Cancelation Request
Cancellation Policy

1. If a customer calls in to request cancellation of their policy, reference the following script.

"I am really sorry to hear that you want to cancel your insurance with our office. Is there anything we can do to change your mind?

What agency did you move your insurance to?

What carrier did they provide you with?

What was the reason you decided to reach out to them and get a quote for your insurance?

Well, I certainly understand, I see that {agentName} is your agent. I will go ahead and let him know that you have requested to cancel tour policies with our agency. Just so you know {agentName} must request the cancellation from the insurance company.

Can you hold tight while I pull up his/her calendar... would (dates open) be okay for a quick call from {agentName}?

**Use the Schedule Call Back Button Above to open agents calendar

Because only the agent on the account has the authority to request the cancelation it’s just easier to schedule a time to get it done… Just tying to make the as easy as possible for you!

Okay… Great… I have {agentName} calendar open would any of these dates be okay for a quick call?... (schedule time using calendar link in Schedule Call Back Button)

Now that we have that scheduled let’s see if I can’t get one more item checked off the list before your call with {agentName}.

So, as company policy we do request you to sign a cancellation form, I can send this to you via DocuSign... is {customerEmail} the best email to send signature request to?

I’m sure you have used DocuSign or a similar program before but, you just sign it on your phone or tablet, really easy.

I know this may seem like a long process, BUT we just want to make sure we have a written record of your request and confirm the correct policy is canceled on the correct day.

I will get the process started for you, and when {agentName} calls you back he/she will confirm the cancelation has been received by your insurance carrier.

Just to make sure I have it correct on my end, You would like to cancel the {policyType} effective {effectiveDate}, is that correct?... Okay I will get this in motion for you.

Again, just want to say thank you for your commitment to our agency while you were with us!"

2. Document the details from your conversation in the cancellation reason field, make sure to include the following.
- Main reason for cancellation:
- Name of New Carrier:
- New Agency Name:
3. You will have a new service tack created for you to send the customer a request for signature on the cancellation form.

Process to save in Task:

Task Title: Send Cancellation form to client – (Client Name)
- Open Shared document folder
- Search Cancellation Docs Folder
- Double click on “Cancellation From”
- Complete fillable sections
- Save completed document in AZ file
- Send Document via DocuSign
- Enter (agent Name) as second signer on the form
- Go back into AZ and complete the task
(Enter process to find document or direct link to fillable cancellation request form: this could be a two stage JotForm or JotForm to pdf)
Reason for cancelation: *
Attached signed policy cancelation form - Required for all cancellations: Copy this link into teams / Countrywide_ACORD 35 - Cancellation Request or Policy Release.pdf

Cancelof
New Vehicle Info

Added vehicles will assume the same coverage as the highest rated full coverage vehicle on the policy unless otherwise stated in the request below.
Type of Change

Remove VehicleAdd VehicleReplace Vehicle
Will this vehicle replace an existing vehicle?

YesNo
What year make model of the vehicle we need to remove:
Date of Purchase

MonthDayYear
Date
New car VIN
New car Year/ Make / Model
Usage
Annual Mileage
What is the coverage desired for the new car?

Same coverage as vehicle being removedChange coverage for new carLiability only
Please include desired coverage for the newly added vehicle
Will the new vehicle have a lienholder:

YesNo
Name of Lienholder
Address of Lienholder

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
New Driver Info
What type of driver change would you like to make?

AdditionRemoval
Relationship to Named Insured:
New Driver Name:

First NameLast Name
Date of Birth

MonthDayYear
Date
Gender

MaleFemale
DL#
Occupation
Good Student Discount:

YesNo
Billing Info

**Please note that not all carriers accept changes to payment plans mid term, not all carrier accept the same payment types. We will have have to verify the change requests below and send you confirmation of the change. By submitting the request below it does NOT imply that the change has/will be made.
Monthly or Annual :
Method of draft:
Name as it appears

First NameLast Name
Name of Bank
Routing #
Account #
Type of Card
Name on Card

First NameLast Name
Card Number
Number of front of card
SVV number on back of card
Expiration Date on Card

MonthDayYear
Date
Billing Zip Code
Add/Replace Lienholder
What action should occur to the Lienholder?

AdditionReplacementRemove
Vehicle VIN# to apply changes to
Name of Lienholder to remove:
Name of Lienholder:
Address of Lienholder

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Add/Change Mortgagee
Type a change

AdditionReplacementRemove
Name of Mortgagee we are replacing
Street address of property
Name of Mortgagee
Loan/Account Number #
Address of Mortgagee

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Claim Info
Commercial Claims Process

Determine if the claim is time sensitive
Was anyone injured?
Where any vehicles involved?
Does the customer need any board-up service or water remediation?

General Claims Questions
What happen?
When did it happen?
Do you have any pictures? Can you send me what you have, if you don't have any can you please take a few of any damage you can see?
Did you get any estimates for damage?

Next Steps for Insured
Let's take a moment to schedule a call with your agent or our claims department.
**Set up customer appointment with the agent or CSR on the account.
On the call with our team they will have next steps for you, again I am sorry this happened, and I will forward all of these details to the team as soon as we get off the phone.
Auto Claims Process

The first questions are always the same!!

Is everyone okay? Do you need any assistance?

Towing/Roadside: Click Here

We will stay on the phone with you as long as you need, We are here for you!

Are you at the scene still?

Did you call the police?

Do you or someone you’re with have a phone you can use to take pictures?

Okay this is what’s going to happen next… I am going to ask you a few questions than provide you some direction to ensure you are taken care of… I have PHONE as your main contact is that the phone you have on you now?... IF that is not a good number, what is the best number for you? As soon as I gather a few more items I will send you a text with next steps.

We do suggest that you call the police to the scene if you have not already. This creates a record of the incident and create a third-party explanation of the incident.

Do not admit fault to the other party, no matter what the situation is.

If the client is still at the scene:

Are you in a safe place to take pictures of the scene? Make sure to take pictures of several angels of the general area, include any road signs, distractions and/or marks on the ground… IF possible, move to the side of the road or to a safe location… Than call the police to request an officer arrive on the scene.

Here is what I need you to do next, I will also send this to you via text… Take pictures of the following & reply to the text I am sending you now: Copy & Paste the below bullets in a text to the client
- Picture of other parties Insurance Card
**Make sure dates are current & todays date is prior to the policies date range
- Picture of other parties Driver’s License
- Picture of the Business card for officer taking reports
If client has left the scene:

Let me just go ahead and document some information about what happened, again very sorry this happened, and we will get things moving on our end.

**Answer the questions on the form and add any details of the accident in the Claims Details section below.

Final steps in the process…

Just so you know we do not submit the claim to your insurance company unless someone was injured or medical was called. Unless it is a clear at fault incident for our customer…. (is it? If yes, call carrier and file claim). With that being said, we suggest that you file the claim on the other party’s insurance, this keeps the claim off your insurance record. We will store all the information you provided along with the photos you sent in your file. Once you get home and have a moment to collect yourself feel free to give me a call back.
Roof/Sidding/Water Workflow

**Do Not insist that any claim will be covered, we have to confirm with an adjuster that any damages were caused by a covered loss.
1. Instruct clinet to take any nessary actions to remediate the damages
  - Board up company: Click Here
  - Water cleanup: Click Here
2. Instruct insured to take pictures, if possible and reasonable, of any damages prior to work being completed.
3. Loginto AMS or Carrier to find the following info, and enter it into the claims details box below.
  - Policy Number:
  - Deductible (Wind/Hail):
  - Water/Sewer Coverage Amount:
  - Water/Sewer Deductible:
4. Document description of claim or possible claim in the claims details box below.
5. Request the client to email copies of any repair estimates they may have obatined prior to calling the claim/possible caim in.
6. If unsure the damage is covered or damage actually exists let the customer know:
  - "We will not file a claim until we know damage exists. We reccomend you contacting a Local Contractor to reivew the damages pior to turining in a claim. We say this because, If you turn in a claim and no damage is actually present or by chance the damage is not covered we do not want a zero pay claim on your reccord. That could count against you in the future. I will provide you a few of our prefered contractors and if you would like you can request one of them to come out and take a look."
7. SET AGENT APPOINTMENT
  - Go back to top of form and confirm appointment is set for the Agent listed on the policy to call the customer back.
  - Use Appointment setting instructions to book appointment on agents calendar.
Glass Claim Steps:
1. Go to carrier or AMS to gather the following info
  - Glass Coverage or Comb Deductible:
  - Policy number:
2. File claim for client with preferred vendor: Click Here
3. Screen shot or enter the confirmation number provided by (preferred glass co.)
4. Doccument date and time if a service call was scheduled while on the call with the customer.
What was the date of the incident/Claim?

MonthDayYear
Date
Any Physical Injuries? or Medical Personnel called?

YesNo
Was the damage caused by wind, hail or water?

WindHailWater
Have you had anyone to your property to provide an estimate for damages and/or repairs?

YesNoReferred Agency Preferred Vendor
Policy Deductible: *
Was a police report made

YesNo
Police Report Number:
Other Party's Insurance Company:
Other Party's Policy Number:
Other Party's Agent Name & Number:
Claims Details:
Should be Empty:

Service/Change/Claims

Customer Info

Policy Info

Service Request Type

Other Change Request

Cancelation Request

New Vehicle Info

New Driver Info

Billing Info

Add/Replace Lienholder

Add/Change Mortgagee

Claim Info