Insurance Account Change Authorization

INSURANCE ACCOUNT CHANGE AUTHORIZATION

Applicant / Insured Information

Policy Information

Policy Number:    Policy Type:

Policy Period From: to

Requested Changes (Check all that apply)

Change mailing address

Change premium payment method

Change named insured / policyholder name

Change coverage limits / coverage type

Add or remove an insured or interest

Beneficiary Designation (if applicable)

Complete beneficiary information below when changing or designating beneficiaries. Percentages must total 100%.

Supporting Documentation

Please indicate documents attached to support the requested change (required where indicated):

Copy of government-issued photo ID

Proof of address (required for address changes)

Voided check or bank letter (required for EFT)

Power of attorney or other authorization (if not applicant)

Exclusions and Limitations

The insurer's acceptance of the changes requested herein is subject to underwriting review, policy terms and conditions, and applicable law. Approval of any requested amendment does not constitute waiver of any policy term, condition, exclusion, or premium adjustment. The following are examples of items that will not be amended through this authorization and remain subject to separate underwriting:

• Coverage for pre-existing losses or conditions not disclosed at inception;
• Matters requiring additional underwriting, inspection, or premium recalculation;
• Changes that would violate statutory or regulatory requirements.

By signing below the applicant acknowledges that the insurer may deny or modify the requested change if any information is incomplete, inaccurate, or if additional documentation is required.

Declaration and Authorization

I certify that the information provided in this Insurance Account Change Authorization is true, complete, and correct to the best of my knowledge. I authorize the insurer to effect the changes indicated above and to obtain verification of any information necessary to process this request, including contacting banks or other institutions for payment authorization where applicable.

I acknowledge and agree that changes requested by this form will become effective as of the date accepted by the insurer and may result in premium adjustments or changes to coverage terms. I further agree to hold harmless and indemnify the insurer from any liability arising from inaccurate information provided by me or failure to provide required supporting documentation.

Requested Effective Date for Change (if different from insurer acceptance):

I certify that I am authorized to request and authorize the changes indicated and that all attached documentation is true and accurate.

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