Pacific Risk Management - Modify Property

Modify Property Coverage

Policyholder Name:
Contact Person :		*
Phone Number:		*
Email Address:		*
Modification:		Add Change Delete
Address of property:
Type of property:	Building	Amount of Coverage:
	Home	Amount of Coverage:
	Contents	Amount of Coverage:
Deductible amount:		$
If you are adding, or moving to, a new location, please complete the following information:
Year Built:
Construction Type:
Square footage:

I understand that completing and sending this form does not bind coverage changes, and that no such changes will be in effect unless, and until, I receive written confirmation of the changes from my insurance agent.
Please note: This is an alternative method for communicating with us. We will contact you as soon as possible.