PERSONAL POLICY CHANGE REQUEST (EXCEPT AUTO) DATE …

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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, No):FAXCOVERAGES / LIMITS OF LIABILITY$$$$$$$$$$$$$$$$$$PREMIUM(Dwell ing Fire Only)(Dwelling Fire Only)OTHER STRUCTURESDWELLINGBLANKET (Includes Dwelling,Other Structures, PersonalProperty, Loss of Use)LIMITCOVERAGESPERSONAL PROPERTYLOSS OF USEPERSONAL LIABILITY EA OCCMEDICAL PAYMENTS EA PERRENTAL VALUEADDITIONAL EXPENSETYPECHANGEPERCENTDEDUCTIBLES%AMOU NTBASEWIND / HAILTHEFTNAMED%%%%%%%%TYPE%TYPECHANGEHUR RICANE *ANNUALHURRICANE *LOC #:EFFECTIVE DATE OF CHANGEEFFECTIVE DATE OF POLICYEXPIRATION DATE$$$$$$MED PAY (Y/N):MED PAY (Y/N):MED PAY (Y/N):# FAMILIES:# FAMILIES:TERR:LOC #:TERR:LOC #:TERR:LOC #.

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

  Policy, Change, Personal, Request, Auto, Expect, Personal policy change request, Except auto