Policy Changes

Business Name / Last Name *

First Name *

Email Address *

Phone Number *

Policyholder Name

Policy Number

Current Insurance Carrier

Other Carrier Name

Policy Type

Requested Effective Date

Preferred Contact Method

What Change Do You Need?

Add Vehicle

Vehicle Year

Vehicle Make

Vehicle Model

VIN

Vehicle Use

Coverage Needed

Lienholder / Finance Company

Purchase Date

Additional Vehicle Notes Upload registration, title, bill of sale, or VIN documents

Replace Vehicle

Vehicle Being Removed

New Vehicle Being Added

Replacement Date

Coverage Needed

Replacement Notes Upload registration, title, bill of sale, or VIN documents

Remove Vehicle

Vehicle to Remove

Date Vehicle Should Be Removed

Reason for Removal

Additional Removal Notes

Add Driver

Driver Full Name

Date of Birth

Driver License Number

License State

Relationship to Policyholder

Date Driver Should Be Added

Upload driver license or related documents

Remove Driver

Driver Full Name

Date Driver Should Be Removed

Reason for Removal

Additional Driver Removal Notes

Change Coverage

Type of Coverage Change

Requested Coverage Change Date

Describe the coverage change you are requesting

Change Address

Current / Old Address

New Address

Type of Address Change

Effective Date

Additional Address Notes

Mortgagee / Lienholder Change

Change Type

Mortgagee / Lienholder Name

Loan Number

Effective Date

Mortgagee / Lienholder Address Upload mortgagee, lienholder, or loan documents

Home / Property Update

Property Update Type

Date Completed / Expected

Describe the property update Upload receipts, photos, inspection reports, or related documents

Business Information Update

Describe what changed in the business Upload business documents, leases, vehicle schedules, payroll records, or related files

Policy Review / Compare Coverage

What would you like us to review? Upload current policy, declaration pages, or renewal documents

Other Policy Change

Please describe the change you need

Additional Information

You may select multiple files. Accepted files: PDF, JPG, PNG, DOC, DOCX, XLS, XLSX.

I understand that submitting this request does not bind, change, add, remove, or cancel coverage. Coverage changes are not effective until confirmed in writing by BiZ Broker and/or the insurance carrier.

This form is for policy change request intake only. No coverage is bound, amended, or cancelled until confirmed in writing.

Contact Information