Homeowner's Insurance Change Request Form

Lewis Insurance Associates now offers you the ability to change the Mortgagee on your Homeowner's Insurance online.

( * indicates required field)

GENERAL INFORMATION:
*Effective Date of Change:	Mo. Day Year
*Insured name:
*Insured Address:
*Policy number:
*Daytime phone number:
*E-mail address:
Change my deductible to:	$250 $500 $1000 $2500
Add coverage for:	Sewer and Drain Backup Ordinance and Law Replacement Cost on my home Replacement Cost on my personal property Increase my personal property. New coverage amount: Increase other structures (added a shed or detached garage, etc) New coverage amount: Add jewelry coverage (if value exceeds $3000 an appraisal is needed) Value and description: Please contact me to review my Dwelling coverage. (please have the square footage of your home available and/or complete this form and return it to us) Other (specify):

I understand that NO changes to my policy or coverage are bound by submitting this online Policy Change Request. This Change request will be considered bound ONLY upon confirmation from my LIA agent. I have read and agree with the above. (Box must be checked before request is sent)