print and mail, fax, or bring in to Big Dan's Insurance Agency.
I, ________________________________request change/s as indicated
to be made to my policy.
Effective Date of Change/s: ______________________ Policy Number:
To change or add a vehicle you must provide one of the following.
The pink slip (signed by both parties), sales contract (from auto
dealer), bill of sale (signed by both parties), or registration (in
your name) for the vehicle you are adding. Without one of these the
change/s cannot be made.
Change Vehicle: You must complete both "Add and Delete Vehicle"
sections to change vehicle/s.
- Add Vehicle: Year/Make/Model _________________________________________
Specify below what limits of coverage to add (Circle Add/Increase)
when adding a
- Delete Vehicle: Year/Make/Model _________________________________________
To change coverages on your policy, circle either Add/Increase or
Delete/Reduce, and then fill in the blanks.
Circle One Add/Increase Delete/Reduce
- Limits of Liability: ________________________.
- Limits of Uninsured Motorist Bodily Injury and Property Damage:
- Comprehensive and Collision with $___________ deductible.
Changes in comprehensive and collision will require an in-office
- Excess medical coverage in the amount of $_____________.
Please read and sign below:
It is understood and agreed that the requested change/s are not valid
unless submitted in writing (signed by the named insured) with all
necessary documentation and appropriate premium and/or fees paid.
Any change/s to a policy can result in increased premium and/or fees
charged by the insurance company (especially "Add or Add/Increase"
change/s). The Broker may also charge a fee (disclosed on the Broker/Customer
Agreement). It is the Customer's responsibility to be aware of and
submit correct documentation along with sufficient funds to facilitate
changes requested of the Broker. Customer agrees they are responsible
for all fees and premiums and if not submitted at the time of this
change request the Broker and/or the insurance company will bill them
for such. All changes must be acknowledged and accepted in writing
by your insurance company. Change/s requested to a policy in lapse
or cancel status will not be made. Customer understands that insurance
company processing of change request/s may take up to 6 weeks. Customer
must pay any bill/invoice they receive from the insurance company,
regardless if the change requested herein is reflected in the bill/invoice.
All fees are fully earned for services rendered regardless of policy
status and/or acceptance of change/s. Processing of change request
form/s by Big Dan's Insurance Agency does not insure that coverage
is now or has ever been in force.
Changes will not be processed without