Request a Policy Change
Intake Form
Name of person completing this form:
*
First Name
Last Name
Title:
*
Business Name
*
Email Address:
*
When does this change need to take effect?
*
Please Select
Effective at Renewal
Effective Today
Effective Another Date (input below)
Effective Date of Change:
*
-
Month
-
Day
Year
Select all that apply:
*
Change to your business plan or operations
Change to your entity (i.e. changing from a Trust to an LLC)
Change in ownership
Change in tenants (provide updated rent roll)
Change in annual sales/receipts or rental income
Change in annual payrolls and/or employee count
Updates to your building (i.e. plumbing, roof, electrical, HVAC)
Increase or decrease property limits or deductible
Increase or decrease auto limits or deductible
Increase or decrease liability limits
Add or remove vehicles
Add or remove drivers
Add or remove locations
Any other changes to your business (please describe below)
Please explain any changes selected above.
*
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