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Acord Commercial Policy Change Request     
 
Welcome to Networked's Online Commercial Policy Change Request wizard. Simply fill out the fields on each page, click the NEXT or BACK
buttons to navigate, and then click the SUBMIT button at the end of the wizard. All form results will be automatically emailed to an underwriter in the form of a completed Acord Change Request.
You can also navigate directly to the topic of your choice by clicking a link below
 |  Auto-Vehicle |  Drivers |  Worker's Compens |  Property/Inland Marine |  General Liab/Umbrella |  Addtl Interest |  Attachments
STEP 1: AGENCY AND PREMISES INFORMATION
AGENCY
Phone (A/C,No,Ext): Fax (A/C, No):
Policy Type:
Property General Liability Motor Carriers
Inland Marine Auto Business Owners
Umbrella Truckers Workers Comp.
Code: NAIC Code:
Sub Code: *Select a company
OR
Enter a company name (if it does not appear in the drop down menu)

Agency Customer ID: Attention:
*Insured's Name: *Agent's Email Address:
Insured's Mailing Address If Changed (INC Zip 4)
*Policy Number: *Effective Date of Change:
Policy Inception Date: Policy Expiration Date:
Adding new line of business to existing policy:
THIS IS AN ACKNOWLEDGEMENT OF YOUR REQUEST. UPON APPROVAL, THE COMPANY’S RECORDS WILL BE ADJUSTED ACCORDINGLY, AND IF A PREMIUM ADJUSTMENT IS REQUIRED, IT WILL BE DONE AT PREMIUM AUDIT OR BY ENDORSEMENT.
PREMISES INFORMATION
Loc # Bld #
Street:
City: County:
State: Zip:
City Limits: Interest:
Year Built: Part Occupied:
NATURE OF BUSINESS/DESCRIPTION OF OPERATIONS BY PREMISE(S)
Loc # Bld #
Description
     
     
 
 
© 2010 by Networked Insurance Agents, Inc., All Rights Reserved.
Networked Insurance Agents (Networked) provides the small to medium sized Independent Insurance Agency access to a large number of preferred insurance products and services. Through access to these major markets, it allows each agency to own 100% of their business and retain their independence. Because of Networked's ability to produce substantial premiums with a number of preferred markets, it provides the Independent Insurance Agent Affiliate the clout that only the larger Regional Brokers enjoy.