NEW CLIENT

Policy Change Request Form

Form Instruction
This form is to be used exclusively by clients of Community Insurance Center, a division of Inner-City Underwriting Agency Inc.

Please use this form to communicate changes you would like to make in your insurance coverage.

However, please note that the compeletion of this form does not alter or change your insurance in any way until it has been confirmed by your account manager in writing or via the issuance of an endorsement to your policy.

If after submitting this information you are not contacted within one business day by your account manager, please call because we may be experieincing a technical difficulty that prevents the full transmission of your request.
Contact Information
Full Name of the person requesting the policy change
TITLE & DEPARTMENT
EMAIL
PHONE NUMBER
Confirm Email*
PREFERRED CONTACT METHOD

PhoneEmailTextInstant MessageOther
Named Insured on the Policy
Policy Number
We can look this information up in our system if you do not have it available
Policy Type
We can look this information up in our system if you do not have it available
Please provide a complete description of the policy change
Example: Please add auto to my policy or add new location
Date you desire change to become effective

MonthDayYear
Date
Should be Empty:

Policy Change Request Form