Request for Policy Change


Important Notice

We appreciate the opportunity to make changes to your policy via email to save you time and make it convenient for you. Please note, however, that no coverage can be bound via email. This means that no additions to your policy, increases in coverage, changes in your policy limits of insurance, changes in items insured under your policy, adding additional vehicles to your policy, etc are effective until confirmed by CBIZ and we have acknowledged the change and that coverage is effective. You can expect confirmation from us via email or snail mail, and by policy endorsement from your insurance company. All policy terms and conditions apply.


To proceed with a change request, please complete the following:


Name:    
Address:    
City/State/Zip:    
E-mail Address:    
Policy #:    
Home Phone:    
Work Phone:    
Fax:    
Contact Me:    By Phone   By Fax   By E-Mail   By Postal Mail
Date to Make Changes  
Effective:  		  
Comments:    


If you would like an auto change, please complete the following:


To Add a Vehicle, Fill Out the Following Form:

Add Vehicle Form
Year Make Model VIN

Usage Annual Miles
Driven		 Comprehensive
Deductible		 Collision
Deductable
 Pleasure
 Business
 Work > 3 Miles
 Work < 3 Miles 		 No Coverage
 100
 250
 500
 1000 		 No Coverage
 100
 250
 500
 1000

Airbags Automatic
Seatbelts		 Alarm
System		 Anti-Lock Brakes (ABS)
  0
  1
  2
   No
  Yes 		  No
  Yes 		    No
    2-wheel ABS
    4-wheel ABS
 
Principal Operator of this Vehicle:   


If you wish to remove a vehicle from your coverage, fill out this form:

Remove Vehicle Form
Year Make Model VIN
           


Remember:  Most states require you to turn your vehicle license tags in to them when you sell a vehicle, unless they were transferred to a new vehicle you acquired. Failure to do this may result in a fine or penalty from the state.


  
 
  
Site Design and Maintenance by Willetts Systems