Archive for the ‘Client Services’ Category

Home Claim

Thursday, May 27th, 2010

Please take a few moments and complete the following information.

All information provided on this information sheet is confidential and will be used solely for the purpose of developing your request.

Name
Contact Phone
Email Address
Policy Number:
Name of Insurance Company on Policy:
Property Address
Street Address
City
State
Zip Code
Loss General
Date of Loss
Time of Loss Discovery
Cause of Damage
Police or Fire Department Called:
If yes, which one?
Property Inhabitable:
Short Description
Online Policy Change Request Disclaimer
Requested Effective Date of Change

Auto Claim

Wednesday, May 26th, 2010

Please take a few moments to complete the following information.

All information provided is confidential and will not be used for any purpose other than its intended use.

Name
Contact Phone
Email Address
Policy Number:
Name of Insurance Company on Policy:
Vehicle Involved
Make
Model
Year
Loss General
Date of Loss
Cause of Damage:
Estimated Damage
The following section is applicable to Accident only
Driver First Name
Driver Last Name
Relationship to Applicant:
Time of Accident
Number of Cars Involved:
Police Notified:
Estimated Percentage at Fault:
Location of the Accident
Street / Highway
City / Town
State
Short Description
Other Party Information (if available)
Other Driver Name
Address
Home Phone
Work Phone
Driver's License
License Plate
License State
Insurance Company
Policy Number
Vehicle Year/Make/Model
Damage Description
The following section is applicable to Theft only
Time Loss Discovered
Date Police Notified
Vehicle Recovered
Date Vehicle Recovered
Short Description
Online Claim Notice

Change of Address

Wednesday, May 26th, 2010

Please take a few moments to complete the following information.

All information provided is confidential and will be used solely for the purpose of processing your request.

Name
Contact Phone
Email Address
Policy Number:
Name of Insurance Company on Policy:
Change Address Information
Old Address:
New Address:
City and Zip
Phone
Questions or Comments
Online Policy Change Request Disclaimer
Requested Effective Date of Change

Delete Driver

Wednesday, May 26th, 2010

Please take a few moments to complete the following information.

All information provided is confidential and will be used solely for the purpose of processing your request.

Name
Contact Phone
Email Address
Address: (optional)
Policy Number:
Name of Insurance Company on Policy:
Delete Driver
First Name
Last Name
Relationship to Applicant:
Questions or Comments
Online Policy Change Request Disclaimer
Requested Effective Date of Change

Add Driver

Wednesday, May 26th, 2010

Please take a few moments to complete the following information.

All information provided is confidential and will be used solely for the purpose of processing your request.

Name
Contact Phone
Email Address
Policy Number
Name of Insurance Company on Policy:
Driver Information
Name
Birth Date
Relationship to Applicant:
Gender
License #
Years Licensed:
If youthful driver, have you completed a state-approved drivers education course approved by the state
Marital Status
Job Description
Which Vehicle does the person drive?
DUI or DWI in last 6 years?
Has your license been suspended in the last 5 years?
Has your license been revoked in the last 5 years?
Do you require a SR-22?
Number of Violations in the last 5 years:
Number of Accidents in the last 5 years:
Online Policy Change Request Disclaimer
Requested Effective Date of Change

Delete Vehicle

Wednesday, May 26th, 2010

Please take a few moments and complete the following information.

All information provided is confidential and will be used solely for the purpose of processing your request.

Name
Contact Phone
Email Address
Address: (optional)
Policy Number:
Name of Insurance Company on Policy:
Delete Vehicle
Year
Make
Model
Vin #
Questions or Comments
Online Policy Change Request Disclaimer
Requested Effective Date of Change

Change Vehicle

Wednesday, May 26th, 2010

Please take a few moments to complete the following information.

All information provided is confidential and will be used solely for the purpose of processing your request.

Name
Contact Phone
Email Address
Address: (optional)
Policy Number:
Name of Insurance Company on Policy:
Delete Existing Vehicle
Year
Make
Model
Vin #
Add New Vehicle
Year
Make
Model
Vin #
Estimated Annual Mileage
Vehicle Use
Miles to Work/School (1 way)
Ownership
Purchased / Leased On
Purchase Price
Primary Driver
Lienholder Name (if leased or financed)
Additional Insured
Coverages Section
Comprehensive Deductible
Collision Deductible
Questions or Comments
Online Policy Change Request Disclaimer
Requested Effective Date of Change

Change Vehicle

Wednesday, May 26th, 2010

Please complete the following information.

All information provided on this information sheet is confidential and will be used solely for the purpose of processing your request.

Contact Information

Add Vehicle

Wednesday, May 26th, 2010

Please complete the following information.

All information provided on this information sheet is confidential and will be used solely for the purpose of processing your request.

Name
Contact Phone
Email Address
Address: (optional)
Policy Number:
Name of Insurance Company on Policy:
Vehicle Information
Year
Make
Model
Vin #
Estimated Annual Mileage
Odometer Reading
Is it new or used?
Vehicle Use
Miles to Work/School (1 way)
Needs Repairs
Ownership
Purchased / Leased On
Purchase Price
Primary Driver
Who's the registered owner of the vehicle?
Lienholder Name (if leased or financed)
Lienholder Name (if leased or financed)
Additional Insured
Coverages Section
Comprehensive Deductible
Collision Deductible
Do you have Loan Gap Coverage?
Questions or Comments
Online Policy Change Request Disclaimer
Requested Effective Date of Change