Effective Date of Change/s: ___________________________ Policy Number:___________________

Change Address to:

_________________________________________________________
Street Address Unit Number

____________________________________________________________________
City State Zip Code

_____________________________
Telephone Number with Area Code

Mailing Address if Different from Above:

_________________________________________________________
Street Address Unit Number

____________________________________________________________________
City State Zip Code

_____________________________
Telephone Number with Area Code

Please read and sign below.
It is understood and agreed that the requested change/s are not valid unless submitted in writing (signed by the named insured) with all necessary documentation and appropriate premium and/or fees paid. Any change/s to a policy can result in increased premium and/or fees charged by the insurance company (especially zip code changes). The Broker may also charge a fee (disclosed on the Broker/ Customer Agreement). It is the Customer's responsibility to be aware of and submit correct documentation along with sufficient funds to facilitate change/s requested of the Broker. Customer agrees they are responsible for all fees and premiums and if not submitted at the time of this change request the Broker and/or the insurance company will bill them for such. All changes must be acknowledged and accepted in writing by your insurance company. Change/s requested to a policy in lapse or cancel status will not be made. Customer understands that insurance company processing of change request/s may take up to 6 weeks. Customer must pay any bill/invoice they receive from the insurance company, regardless if the change requested herein is reflected in the bill/invoice. All fees are fully earned for services rendered regardless of policy status and/or acceptance of change/s. Processing of change request form/s by Big Dan's Insurance Agency does not insure that coverage is now or has ever been in force.

____________________________________________________/_________________________
Customer's Signature / Date
Change/s will not be processed without signature.