Insurance Service Upgrade Form

INSURANCE SERVICE UPGRADE FORM

Use this form to request an upgrade to an existing insurance policy or to add new services or coverages to a current policy. Complete all applicable sections and provide required supporting documentation. The applicant certifies under penalty of law that the information supplied is true and complete to the best of their knowledge and authorizes the insurer to process the requested change in accordance with the policy terms and any applicable endorsements.

Applicant / Insured Information

Date of Birth:    Phone:    Email:

Current Policy Details

Policy Number:    Policy Type:

Policy Effective Date:    Policy Expiration Date:

Requested Service Upgrade

Requested Upgrade Effective Date:

Increase policy limits    Add rider / endorsement    Add new coverage module
Change deductible    Modify payment option

Coverage Options

Select coverage options to be added or modified:

Collision Coverage    Comprehensive Coverage    Personal Liability
Medical Payments    Rental Reimbursement    Loss of Use

Premium Adjustment & Payment

One-time payment    Monthly installment    Automatic bank withdrawal

Exclusions and Limitations

Upgrades are subject to the insurer's underwriting guidelines, applicable policy terms, exclusions and limitations. Coverage additions or limit increases will not apply to losses that occur prior to the effective date approved by the insurer. The following are typical exclusions that remain in effect unless expressly amended by endorsement: intentional acts, fraud, wear and tear, pre-existing damage, uninsured activities not covered by the policy, and any exclusions stated in the existing policy or subsequently issued endorsements.

I acknowledge that I have read and understand the exclusions and limitations that may apply to the requested upgrade.

Beneficiary / Payee Information

Required Documentation Checklist

Please include copies of the applicable documents with this request:

Recent valuation or appraisal    Photographs showing condition    Repair or replacement estimates
Copy of government-issued ID    Other supporting documentation (describe below)

Declaration and Authorization

By signing below, I certify that the information provided on this Insurance Service Upgrade Form is true and complete. I understand that approval of the requested upgrades is subject to underwriting review and acceptance by the insurer. I authorize the insurer and its representatives to obtain and verify any information necessary to evaluate this request, including but not limited to claims history, inspection reports, and valuation data. I acknowledge that any material misrepresentation or omission may result in denial of the request or rescission of coverage in accordance with the policy terms.

I further understand that additional premiums, endorsements, or revised policy documents may be issued to reflect approved changes, and that coverage for the requested upgrade will become effective only upon issuance of such endorsement or written confirmation from the insurer specifying an effective date.

Warning: Any person who knowingly submits false information or omits material facts may be subject to criminal or civil penalties under applicable law.

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