Policy Change Request Form

Marine - Scheduled Equipment

Action: Add Change Delete

ID / Serial Number

Date Purchased

Amount of Insurance

If you are changing the name of your business, please click here to e-mail Harriett Loftus ( ). A commercial insurance specialist will contact you to verify the name change.

If you are adding or deleting a property, please click here to e-mail Harriet Loftus ( ). A commercial insurance specialist will contact you to request the pertinent information.

Contact Information
Company: (if applicable)
Name:
Address:
City:
State:	Zip:
Daytime Phone:	Night Phone:
E-mail Address:

Current Insurance Information
Company Name:
Policy Number:
Policy Expiration Date:
Date you want change to take effect:

Vehicle Information
Car #1	Action: Add Change Delete
	Year	Make	Model	Body Type	Vehicle ID Number

Use			Num. of miles to work/school?		Airbags	GVW / GCW
			Under 15 15 or more		Y N
If vehicle is kept at an address other than that listed above, please indicate below
Location City: State: Zip:


Car #2	Action: Add Change Delete
	Year	Make	Model	Body Type	Vehicle ID Number

Use			Num. of miles to work/school?		Airbags	GVW / GCW
			Under 15 15 or more		Y N
If vehicle is kept at an address other than that listed above, please indicate below
Location City: State: Zip:

Driver Information
Driver #1	Driver's Name		Action: Add Change Delete
			Years Licensed:		State Licensed:
Relation	DOB	Sex	% Use Vehicle	DL Number
		M F

Driver #2	Driver's Name		Action: Add Change Delete
			Years Licensed:		State Licensed:
Relation	DOB	Sex	% Use Vehicle	DL Number
		M F

Umbrella
Limit of Liability:
Retained Limit:
Other, describe:

Additional Interest
Type of Interest:
Name:
Address:
City:	State: Zip:
Certificate Required:	Yes No
Interest in the following:
Premises:
Building:
Vehicle:
Boat:
Scheduled Item Number:
Other:
Item Description:

Additional Comments

Submission of a loss notice does not represent, assure or guarantee that coverage will be provided by your insurance program. If further information is required, you will be contacted by either a representative of The Zutz Group or your insurance company.

Any person who knowingly, and with the intent to injure, defraud, or deceive any insurance company, files a statement of claim containing any false, incomplete or misleading information is: guilty of a felony and/or subject to criminal prosecution, civil penalties; punishable by imprisonment or fines.

Please click the "Change Request " button to send your request.

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