Robert Hoffman Insurance - Request to Add or Delete a Loss Payee

Request to Add or
Delete a Loss Payee

Policy Change Disclaimer
Please note that this submission is a request. It is important to include as much information as possible in order to process your request. Insurance coverage changes and new coverage are not effective and are not bound until your receive confirmation from us.

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.

Requested By:		Date
E-mail Address