Request a Change
Intake Form
Business/Policyholder's Name:
*
Policy Number (optional):
Email Address:
*
Type of Change Requested:
Change to Mailing/Billing Address
Adding or Removing Location(s)
Adding or Removing Driver(s)
Adding or Removing Vehicle(s)
Change to your business plan
Change in ownership
Change to your payrolls
Change to your sales/receipts
Change to your stock/business personal property
Adding a new service to your business
Change to your entitiy (i.e. going from a Sole Proprietor to a Corp)
Becoming aware of a claim
Other
New Mailing/Billing Address:
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
What location(s) are you adding or removing:
For new locations being added, please reply to the below. - Address: - Year Built: - Central Station Burglar Alarm? Y/N - Central Station Fire Alarm? Y/N - Is the interior of the building sprinklered? Y/N - Building Limit (if applicable): - Business Personal Property Limit (if applicable): Important Note: If the building is over 30 years old, please include when the following have been updated: Roof, Electrical, Plumbing, HVAC.
What driver(s) are you adding or removing?
For new drivers being added, please reply to the below. - Full Name: - Date of Birth: - Driver License Number:
What vehicle(s) are you adding or removing?
For new vehicles being added, please reply to the below. - Year: - Make/Model: - VIN:
Explain the change to your business plan:
Include the ownership change:
For new ownership information, please reply to the below. - Full Name: - Title: - Ownership %:
Explain change in payrolls/employees:
Updated sales figure:
Explain change in stock or business personal property:
What new service are you adding to your business:
Changing Entity to:
Sole Proprietor
Partnership
LLC
Corporation
Trust
Association
Other
Explain the claim:
Explain the type of change you need to make to your policy:
Optional File Upload:
Browse Files
Drag and drop files here
Choose a file
Cancel
of
Confirmation
I understand no update/change to my coverage is finalized until the carrier receives all necessary information and confirms the change request to my policy.
I contest that I have the authority to request this policy change.
*
Name of Signer:
*
First Name
Last Name
Print Form
Save
Submit
Clear Form
Should be Empty: