Holder Insurance Agency

Request to Add or Delete a Location

Please note that this form is for notification purposes and any changes will not be binding until you receive confirmation from us. If you do not hear from us in a reasonable amount of time, ASSUME WE DID NOT GET THIS REQUEST and call our office (800) 237-7795.

I, the policy holder, understand that filling out this form IS NOT binding. Changes ARE ONLY considered binding when I hear back from my agent indicating that they have received my request and will be processing it.

Insured's Name (required)

Policy Number: (required)

Effective Date of Change:

Add

Delete

Location:

Street or P.O. Box
City
State
Zip

Interest in Policy:

Owner

Tenant

Year of Construction	Building Value	Square Footage

Contents Value	Number of Floors	Estimated Sales

Central Alarm	Installed By:

If Adding a Location, Describe Operations at this Location:

Certificate Holder: Additional Insured

Mortgagee

Mortgagee's Name, Address & Loan Number if Required:

Name
Street or P.O. Box
City
State
Zip
Phone
Fax Number
Loan Number if Applicable

Comments:

Requested By: Date

E-Mail:

Where did you hear about our agency?