Insurance Servicing Form

INSURANCE SERVICING FORM

Use this form to request administrative changes or servicing to an existing insurance policy. Complete all applicable sections and provide supporting documentation where requested. Submission of this form authorizes the insurer and its authorized representatives to process the requested servicing, subject to policy terms, underwriting review and applicable premiums, fees, or endorsements.

Applicant / Insured Information

Policy Details

Policy type: Auto Homeowners Life Health Business Other:

Requested Servicing (select all that apply)

Change of address
Change of beneficiary / beneficiary designation
Increase coverage / add endorsement
Decrease coverage
Add named insured
Remove named insured
Change payment method / billing
Cancel policy
Reinstate policy
Issue duplicate ID card / policy proof
Update contact information
Other:

Service Details

Beneficiary Information (complete if applicable)

Primary beneficiary

Contingent beneficiary

Coverage Options / Included Coverages

Liability
Collision
Comprehensive
Medical payments / Personal injury protection
Uninsured / Underinsured motorist
Personal property coverage
Umbrella / excess liability
Other specified perils:

Exclusions and Important Notices

The following are examples of standard exclusions that may apply to policy changes or coverages: intentional acts or criminal conduct by the insured; wear and tear, gradual deterioration, or mechanical breakdown; war or nuclear hazards; losses arising from contractual liability except as otherwise stated in the policy; fraudulent claims. This form does not alter policy terms. Any requested change is subject to underwriting review and written endorsement or endorsement rejection by the insurer.

I acknowledge that I have read and understand the foregoing exclusions and that insurer approval is required for changes to be effective. Acknowledged

Documentation Checklist

Provide copies of documents as applicable (check all provided):
Proof of identity
Proof of ownership (bill of sale, title)
Police report (for loss claims)
Medical reports (if applicable)
Photographs or damage estimates
Other supporting documents:

Declaration and Authorization

By signing below I affirm that the information provided on this form is true, complete and accurate to the best of my knowledge. I understand that knowingly submitting false information or materially misleading information in connection with an insurance application or servicing request may constitute insurance fraud and may result in denial of requested changes, cancellation of coverage, or civil or criminal penalties where applicable.

I authorize the insurer, its agents, representatives and service providers to obtain, verify and exchange information relevant to this servicing request, including underwriting, claims, and medical or financial records where applicable. I consent to the release of information necessary to effectuate the requested change to the named agent or broker identified on this form.

I understand that the insurer may require additional documentation and that any change requested by this form will not take effect until accepted and evidenced by a written endorsement or other written confirmation from the insurer. I accept responsibility for any change in premium or fees arising from the requested servicing.

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