Transcription of COMMERCIAL POLICY CHANGE REQUEST DATE …
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COMMERCIAL POLICY CHANGE REQUEST DATE …
The ACORD name and logo are registered marks of ACORDSHORT DESCRIPTION OF CHANGES / REMARKS (ACORD 101, Additional Remarks Schedule, may be attached if more space is required)POLICYTYPEPROPERTYGENERAL LIABILITYINLAND MARINEAUTOUMBRELLAWORKERS COMPTRUCKERSBUSINESS OWNERSMOTOR CARRIERSTHIS IS AN ACKNOWLEDGEMENT OF YOUR REQUEST . UPON APPROVAL, THE COMPANY'SRECORDS WILL BE ADJUSTED ACCORDINGLY, AND IF A PREMIUM ADJUSTMENT ISREQUIRED, IT WILL BE DONE AT PREMIUM AUDIT OR BY NUMBERCARRIERNAIC CODEACCOUNT NUMBERPOLICY EXPIRATION DATEPOLICY INCEPTION DATEEFFECTIVE date OF CHANGEATTENTIONINSURED'S NAME AND MAILING ADDRESS, IF CHANGED (INC ZIP+4)NAMED INSUREDFAX(A/C, No):AGENCYNAME:CONTACT(A/C, No, Ext):PHONESUBCODE:CODE:AGENCY CUSTOMER ID:ADDRESS:E-MAIL 1991-2012 ACORD CORPORATION. All rights 1 of 2 ACORD 175 (2012/04) COMMERCIAL POLICY CHANGE REQUESTDATE (MM/DD/YYYY)$COST NEWSYMCOLLOTC SYMCOMP /$TOTAL PREM:OTCFGREIMBRENTCOLLCOMP/LSPFTWFTFC OF LSPEC& LABORTOWINGMOTORUNDRINSMOTORUNINSMED PAYFAULTADD'L NO-FAULTNO-LIABCOVERAGESCHECKFOR HIRESERVICERETAILCOMM'LFARMPLEASUREUSE15 MILES +< 15 MILESWORK / SCHOOLDRIVE TOZIPSTATECOUNTYCITYSTREET (Required in KY)GARAGINGADDRESSSTATELICTERRGVW / GCWCLASSSICFACTORSEAT CPRADIUSFARTHEST TERMINALNET VEHDR/CR.
The ACORD name and logo are registered marks of ACORD SHORT DESCRIPTION OF CHANGES / REMARKS (ACORD 101, Additional Remarks Schedule, may be attached if more space is required)
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