Commercial Liability Change Request

Policy Information:
Insured name
Address
City
State*
Zip
Policy number
Policy inception date
Policy expiration date
Effective date of change
General Liability - Limits:
General aggregate ($)
Products and completed operations aggregate ($)
Personal and advertising injury ($)
Each occurence ($)
Damage to rented premises ($)
Medical expense (any one person) ($)
Employee benefits ($)
General Liability - Schedule of Hazards:
Hazard 1
Type of change
Location number
Classification
Class code
Premium basis
Territory
Hazard 2
Type of change
Location number
Classification
Class code
Premium basis
Territory
Hazard 3
Type of change
Location number
Classification
Class code
Premium basis
Territory
Hazard 4
Type of change
Location number
Classification
Class code
Premium basis
Territory
Additional Interest:
Change request type
Type of interest
Name of additional interest
Address
City
State*
Zip
Reference number
Item description
Is certificate required
Interest in premises number
Interest in building number
Interest in vehicle number
Interest in boat number
Interest in scheduled item number
Interest in other number