| *Effective Date of change: |
Mo.
Day
Year |
| *Insured Name: |
|
| *Phone Number: |
|
| *E-mail address: |
|
| *Policy Number : |
|
| Fax Number: |
|
| *Current Mailing Address: |
|
| *City: |
|
| *State: |
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| *Zip: |
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| New Mailing Address: |
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| If this change is for your auto policy please answer the following questions: |
Will your vehicle(s) be
garaged/kept at this address? |
|
If not, at what address will
it be garaged? |
|
Has the use of your
vehicle changed? |
Yes
|
| Vehicle 1: |
Vehicle Usage: |
|
If commuting,
number of miles one way: |
|
If commuting,
number of
days per week: |
|
| Annual Mileage: |
(average is 10-15,000) |
| Vehicle 2: |
Vehicle Usage: |
|
If commuting,
number of miles one way: |
|
If commuting,
number of
days per week: |
|
| Annual Mileage: |
(average is 10-15,000) |
| Vehicle 3: |
Vehicle Usage: |
|
If commuting,
number of miles one way: |
|
If commuting,
number of
days per week: |
|
| Annual Mileage: |
(average is 10-15,000) |
| |
|
Do you have any other
policies that need an
address change? |
Home
Life |
PCL/Umbrella
Other:
|
| |
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) |
|
