PERSONAL POLICY CHANGE REQUEST (EXCEPT …

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Page 1 of 4ACORD 70 (2009/06) 1992-2009 ACORD CORPORATION. All rights ACORD name and logo are registered marks of ACORDDATE (MM/DD/YYYY) PERSONAL POLICY CHANGE REQUEST (EXCEPT AUTO)PERMISSIBLE "TYPE OF CHANGE " CODES: (A) ADD, (C) CHANGE , (D) DELETEBILLINGDIRECT BILLATTENTION:ACCT#:POLICYDIRECT BILLACCTAGENCY BILLFULL PAYPAYMENT PLANANNUALSEMI-ANNUALQUARTERLYBI-MONTHLY MONTHLYPAYORINSUREDMORTGAGEEPREMIUM FINANCED? (Y/N)FINANCE COMPANY:NAMED INSUREDCASHPAYMENT METHODCHECKCREDIT CARDEFTPAYROLLPRE-AUTHORIZEDDEDUCTIONDRA FT/CHECK (PAC)(Not applicable in NC)NAIC CODECARRIERPOLICY NUMBERINSURED'S NAME AND MAILING ADDRESS (Inc ZIP+4), IF CHANGEDUMBRELLAWATERCRAFTDWELLING FIREINLAND MARINEMOBILE HOMEHOMEOWNERPOLICYTYPEE-MAILADDRESS:AGE NCY CUSTOMER ID:CODE:SUBCODE:PHONE(A/C, No, Ext):CONTACTNAME:AGENCY(A/C.)

rating / underwriting % frame masonry mfg home steel masonry veneer fire resistive poured concrete log. construction type. below average good excellent average

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