Please be advised that completing this form does not immediately extend insurance coverage to a newly acquired vehicle or personal property nor does it immediately increase any coverages or amend any deductibles on your current policies. Any change that is requested will not take effect until our representative formally submits the request to your insurance company. All changes must meet your insurance company's underwriting guidelines. We will confirm all requests by e-mail.

In order to ensure your change request is processed promptly and accurately, it is important that you enter all information that is requested and that you provide as much detail as possible in the description box.

	PERSONAL INFORMATION
	Name: Policy Number: (required) Type of Policy: business insurance car motorcycle boat house condominium tentant rental property cottage

	CONTACT INFORMATION
	E-mail address: (required) Home Telephone: Office Telephone:

	CHANGE REQUEST INFORMATION
	Effective Date of Change: (required) Effective Time of Change: (required) Detailed Description of Policy Change that you are requesting: If you're adding a vehicle, please make sure you provide the VIN number (vehicle serial number), exact make and model and if it's a new or used car and the coverages you would like applied.