Insurance Name Correction Form

INSURANCE NAME CORRECTION FORM

Use this form to request a correction to the name on an existing insurance policy record. Complete all applicable fields, attach or describe supporting documentation, and sign the certification authorizing the insurer to make the requested correction. Submission of this form does not itself create an endorsement or change in coverage until accepted and processed by the insurer.

Applicant / Insured Information

Date of birth:

Policy Details

Insurer name: Policy number:

Coverage amount: Deductible: Annual premium:

Policy period from: to:

Coverage Sections Affected

Indicate which coverage lines this name correction affects (check all that apply):

Liability Comprehensive Collision

Medical Payments Uninsured Motorist Personal Property

Correction Requested & Reason

Marriage/Name change Divorce Court order/legal change

Typographical error on policy Other — specify:

Effective date of name change or date of error:

Supporting Documentation Checklist

Provide copies of required documentation. Check items enclosed or indicate that copies will follow.

Government-issued photo ID (driver's license, passport)

Marriage certificate

Court order or legal name change document

Deed poll or statutory declaration

Beneficiary Information (if applicable)

Provide beneficiary details that may be affected by the name correction. If more space is needed, attach a separate sheet signed and dated.

Relationship: Percentage:

Relationship: Percentage:

Exclusions and Limitations

The insurer reserves the right to verify submitted documents and may require certified copies. This name correction is administrative and, unless an official endorsement is issued by the insurer, does not change the terms, coverage limits, effective dates, or premium obligations of the policy except as expressly stated in an endorsement. The insurer may deny a correction request if evidence is incomplete, the correction would be contrary to law, or fraud is suspected.

Applicant acknowledges that any endorsement fee, additional premium or changes required to process the correction may apply and will be communicated separately. The insurer is not liable for payments, claims or obligations that arise prior to the effective date of any accepted change, unless otherwise agreed in writing.

I acknowledge and understand the exclusions and limitations stated above.

Declaration and Authorization

I certify that the information provided on this form is true and correct to the best of my knowledge. I authorize the insurer and its agents to update policy records to reflect the corrected name and to obtain any necessary documentation to verify this request. I understand that making a false statement to obtain an administrative change may subject me to civil or criminal penalties and may result in denial of coverage or rescission of the policy.

Sign Now