Policy Change Request

The following form is provided to you for making changes or requests on your existing policies. By submitting this form you understand that no coverage or premium adjustment of any kind is bound until you receive written notice from us.

Policy Change Request

* indicates required fields

General Information

Name*

Company Name (If For a Business)

Email*

Phone*

Current Insurance Information

Insurance Company Name

Policy Number

Policy Expiration Date

Date You Would Like Changes to Take Effect

Describe Requested Changes

Name

This field is for validation purposes and should be left unchanged.

Insurance products are offered through the following insurers: Chubb Group (Warren, NJ); The Travelers Indemnity Company (Hartford, CT); Philadelphia Indemnity Insurance Company (Bala Cynwyd, PA); The Progressive Corporation (Mayfield Village, OH); The Hartford Insurance Group, Inc. (Hartford, CT); GEICO; Zurich American Insurance Company (Schaumburg, IL); HISCOX (Chesapeake, VA); Lloyds of London (New York, NY); Mutual of Omaha (Omaha, NE); Principal Financial Group (Des Moines, IA); and other unaffiliated insurers.

Insurance services are provided by an independent insurance agency. Blue Bear Insurance Services and its producers are licensed in the states where services are offered. License numbers are available upon request. Availability, eligibility, and coverages may vary by state. Not all products are available in all states.