You may get a premium quotation on line for all your Personal and Business insurance needs, such as: Auto, Homeowners, Renters, Condo Units, Individual Health, Group Health, Short Term Health, International Health, and Life Insurance - Businessowners Insurance, General Liability Insurance Workers Compensation Insurance for Offices, Retail and Wholesale Stores, Service Businesses, Manufacturers, Contractors and much more.

All Personal and Commercial Insurance Programs can be custom tailored to fit your individual and business specific needs.

Insurance Service Request

Short description of change:
Effective Date of Change: *	mm/dd/yy
Please read below EFFECTIVE DATE OF CHANGE MUST BE CONFIRMED BY THE INSURANCE AGENT BY PHONE FAX OR EMAIL. IF NOT CONFIRMED WITHIN 24 HOURS, PLEASE CALL OUR OFFICE AT 847-967-8850 IMMEDIATELY . THANK YOU
This form is used to request a change on your insurance policy
Name of person making the request
Name:*
Title:
Organization:
Work Phone:
Home Phone:
Fax:
E-mail:*
Insured Information
Name:
Address:
City:
State:
Zip Code:
Phone Number:
Fax Number:
Policy/Account number
Policy Number:
Policy Type - Auto, homeowners, business, etc..:

Vehicle make:	Change Add Delete
Model:
Vehicle year:
Serial number:
Other information:
Property Information (If Applicable)
Type of building - office, apartment, one or more family home, etc..:
Do you own or lease your space: *
Maine occupancy of building: *
Building construction: *
Height of building: *
Is building sprinklered?: *
If yes, please write down percentage: sprinklered:
Address:*
City:*
State:*
Zip Code:*
County:*
Total square footage of your building:*
Total square footage of your space: *
Approximate year the building was built: *
Year building was updated: *	Wiring	roof	plumbing		heating

Please check all the features that apply to your building. *It's important that you check all applicable items:*	Sprinkler system Smoke detectors Burglary alarm Security guard Fire alarm			Exterior lighting Barred windows Circuit breakers Fuses None
Insurance Coverage Information
Change building limit to:	$
Change business personal property limit to:	$
Change or add other property coverage such as: Electric Signs, Glass, Awnings, Etc. (Please Describe)
Change general liability limit/auto liability to:	100,000 300,000 500,000 1,000,000 (combined limit) 50/100 100/300 250/500 500/500 (split limits)
Change building/personal property/auto deductible to:	$250 $500 $1,000 $2,500 $5,000
	Other Deductible Amount:
Additional Interest Information
Change, add or delete mortgagee, loss payee or additional insured?	Change Add Delete
Please select the interest type - More than one choice may be made by holding down the "Ctrl" key:
Additional Interest name:
Department:
Address:
City:
State:
Zip code:
Loan Number:
Phone:
Fax:
E-mail address:
Additional Information/Comments