Policy Servicing Change Request Intake Form

Intake form for client policy servicing requests such as address changes, coverage updates, and other policy modifications, with routing to the appropriate servicing workflow.

Submission Notice

• What change are you requesting?
• Request type
• Requested effective date
  Enter the date you want the change to take effect, if known.

Policy Information

• Policy number
• Line of business
• Policyholder name
• Preferred contact email
  Used only if we need to follow up about this request.
• Preferred contact phone
  Used only if we need to follow up about this request.

Change Details

• New mailing address
• Date the address changed
• Coverage change requested
• Coverage change details
• Policy modification details
• Supporting documents
  Upload any documents needed to verify or process the change, such as proof of address or authorization forms.

Authorization and Verification

• Your relationship to the policy
• Authorization attached
  Check this if you are submitting on behalf of the policyholder and have authorization on file or attached.
• Verification notes

Routing and Follow-Up

• Preferred contact method
• Urgent processing needed?
• Reason for urgency