PERSONAL POLICY CHANGE REQUEST (EXCEPT AUTO)

PART COMP YEARABOVE GROUND ONMASONRY FLOORABOVEGROUNDABOVE GROUND NOTON MASONRY FLOORBELOWGROUNDMANNEDSECURITYOFF PREMISESTHEFT EXCLBURGLARHSEHLDSWIMMING POOLYESDATE (MM/DD/YYYY)PHONEAGENCY(A/C, No, Ext):POLICYFAXTYPE(A/C, No):COMPANYNAIC CODE:ATTENTION:CODE:SUBCODE:AGENCY CUSTOMER IDPOL#:NAMED INSUREDACCT#:INSURED S NAME AND MAILING ADDRESS (Inc ZIP+4), IF CHANGEDEFFECTIVE DATE OF CHANGEINCEPTION DATE OF POLICYEXPIRATION DATEIF DIRECT BILL: CHANGE BILLING PLAN TO:ADDCHANGEDELETEHO FORMA. DWELLINGB. OTHERC. PERSONALD. LOSS OF USEE. PERSONALF. MEDICALSTRUCTURESPROPERTYLIABILITYPAYMEN TS$$$$$$ADDCHANGEDELETEA.

ACORD 70 (2004/05) Any person who knowingly and with intent to defraud any insurance company or another person files an application for insurance or statement of claim containing any materially false information, or conceals for the purpose of misleading information concerning any fact

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