The Phoenix Group - Insurance Personal Business Employee Benefits

Friday 07/30/2010

Please indicate your name, email address and phone number so that we may follow-up with you.
Your Full Name:
Your EMail Address:
Your Phone Number:

Equipment Change

PERSONAL INFORMATION

Date:
Insured Business/Name:
Insured Business/Email:
Effective Date:

ADD

Year:
Make:
Model:
Serial Number:
Insured Value:	$

Additional Interest and/or Loss Payee Name and Address (If any)
Name:
Address:
City:
State:
Zip:
If non-owned, leased or rented equipment, please indicate length of time equipment will be used and for what purpose.
Length of Time:
Purpose:

DELETE

Year:
Make:
Model:
Serial Number:

OTHER
Please Explain:

Acknowledgement of this form will be your copy of our change request sent to the insurance company.
If you do not receive an acknowledgement within 5 days, please notify us.

No coverage changes will be in effect until you receive confirmation from our office.