Business Name
Your Name *Required
Your Business Telephone
Your E-mail Address *Required

What effective date do you want for this change:

Policy #

AUTOMOBILE

ADD DELETE
Year
Make
Model
Serial Number
Cost New of Vehicle $
Radius of Operation
Gross Vehicle Weight
Garaging: Town State Zip Code
Comprehensive Deductible $
Collision Deductible $
Is there a loan on the vehicle? Yes No
Is this a Leased Vehicle? Yes No
Name of Lending / Leasing Company:
Address
City State VT MA ME NH NY VT Zip
Do you want to make another Automobile Change:
Please specify other automobile change here.



DRIVERS
ADD DELETE

Full Name
Date of Birth
Social Security #
Drivers License Number
State where Licensed VT MA ME NH NY VT
Do you want to make another driver change?
Please specify other drivers change here.




EQUIPMENT
ADD DELETE
This area is for Tools and Equipment other than Autos
Year
Make
Model
Serial Number
Cost or Value $
Is there a loan on this equipment Yes No
Is this Equipment Leased? Yes - equip leased No - equip leased
Name of Lending / Leasing Company:
Address
City State VT MA ME NH NY VT Zip
Do you want to make another Equipment Change?
Please specify other equipment change here.



BUILDINGS
Physical Address
City State VT MA ME NH NY VT Zip
ADD DELETE CHANGE
If CHANGE: New Value $:
If ADD: Value $
Construction of Building
Year Built
Square Foot
Sprinkler System? Yes - sprinkler No - sprinkler
Burglar Alarm? Yes - burglar alarm No - burglar alarm
Fire Alarm? Yes - fire alarm No - fire alarm
Does this Fire Alarm system dial into a Fire Dept. or Security Co.? Yes - Fire Alarm dial into Fire or Security No = Fire Alarm dial into Fire or Security
Is there a loan on this Building? Yes - loan on building No - loan on building
Name of Lending / Leasing Company:
Address
City State VT MA ME NH NY VT Zip
Do you want to make another Building Change?
Please specify other building change here.



BUILDING CONTENTS
Physical Address
City State VT MA ME NH NY VT Zip
ADD DELETE CHANGE
If Change: New Value $:
If Add: Is this in connection with a new building listed above? Yes No
Value $:
Do you want to make another Building Contents Change?
Please specify other Building Contents change here.

BUSINESS OPERATION ADD, DELETE, OR CHANGE

Estimated Gross Receipts:

If ADD: Description of New Operations:
Payroll Assigned to the New Operation $:
Estimated Gross Receipts $:

If DELETE:
Description of Operations to Delete:
Payroll Assigned to the Deleted Operation $:
Estimated Gross Receipts $:

If CHANGE:
Description of Operation to Change:
New Payroll $:
New Gross Receipts $:

Do you want to make another Business Operations Change?
Please specify other change here.

WORKERS COMPENSATION ADD, DELETE, OR CHANGE

If ADD:
Description of New Operations:
Payroll Assigned to the New Operation:

If DELETE:
Description of Operations to Delete:
Payroll Assigned to the Deleted Operation

If CHANGE:
Description of Changed Operations:
New Payroll

Do you want to make another Workers Compensation Change?
Please specify other change here.