Insurance Home Policy Changes

INSURANCE HOME POLICY CHANGES

Insured Information

Policy Details

Policy Type:    Primary Insured:

Policy Period: From to    Annual Premium:

Requested Changes

Check all change requests that apply and provide the requested detail fields below. All changes are subject to insurer underwriting approval and premium adjustment.

Add new coverage or endorsement
Remove coverage or endorsement
Change coverage limits or sublimits
Change deductible amount
Add named insured or resident relative
Remove named insured
Add or change mortgagee / loss payee
Change mailing / billing address
Other (describe below)

Proposed Coverage Adjustments

Complete proposed amounts for the coverages to be changed. If no change, leave blank.

Dwelling (Coverage A) — Proposed:    Deductible — Proposed:

Personal Property (Coverage C) — Proposed:    Liability — Proposed:

Other Structures (Coverage B) — Proposed:    Loss of Use — Proposed:

Mortgagee / Loss Payee

If adding or changing a mortgagee or loss payee, complete the following:

Supporting Documentation Checklist

Please attach required documentation to support requested changes. Check all that are attached or will be provided.

Property inspection report
Photographs of property / damage (if applicable)
Contractor or repair estimates
Purchase receipts or proof of ownership for high-value items
Other supporting documents (describe below)

Exclusions, Limitations and Important Notices

I acknowledge that requested changes are subject to insurer underwriting review. No requested change will become effective until the insurer issues an endorsement or other written confirmation specifying the effective date and any premium adjustment. Changes will not broaden coverage for perils or limits excluded under the existing policy unless expressly stated in an endorsement signed by an authorized representative of the insurer.

Typical exclusions that may continue to apply include, but are not limited to: flood, earth movement (including earthquake and sinkhole), wear and tear, gradual deterioration, mechanical or electrical failure not caused by a covered peril, government action, and intentional acts. Additional exclusions or sublimits may apply to specific endorsements.

By submitting this form, the insured certifies that all statements and representations are true and complete to the best of the insured's knowledge. Material misrepresentation or omission may result in denial of coverage, rescission of coverage, or retroactive adjustment of premium and terms. The insured authorizes the release of underwriting, claims, and inspection information necessary to process this change request.

Certification and Authorization

I certify under penalty of perjury that the statements contained in this form and any attachments are true and complete. I understand that acceptance of the requested changes is subject to underwriting review and issuance of a formal endorsement or revised policy declarations. I agree to pay any additional premium and fees associated with the changes if accepted by the insurer. I further authorize the insurer, its representatives, and its agents to obtain, use and disclose information necessary to evaluate and implement this request.

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