Holder Insurance Agency

Request to Add or
Delete a Loss Payee

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

E-mail Address:

Policy Number:

Effective Date of Change:

Add

Delete

Certificate Holder: Additional Insured

Loss Payee

Loss Payee's Name, Address & Loan Number if Required:

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

If Adding a Loss Payee, indicate if for Business Personal Property or Equipment:
Business Personal Property	Equipment

If Equipment, Describe Indicating Serial Numbers and Value to Insure:

Year:

Make:

Model:

Serial #:

Value:

Additional Information
In the box below, please provide any additional information you feel may be necessary
for this Loss Notice form.

Requested By:		Date
E-mail Address
Where did you hear about our agency?