Mortgagee Change Request Form

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

( * indicates required field)

GENERAL INFORMATION:
*Insured name:
*Policy number:
*Daytime phone number:
*E-mail address:
*New MortgageCompany:
*New Mortgage Company Address:	(this usually varies from where payments are mailed.)
Loan Closing Date:	Mo. Day Year
Will the new mortgage be escrowed?:	Yes No
What mortgage is this?:	1st 2nd
Should the 2nd mortgage be deleted?:	Yes No
Additional Comments:

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)