Berends, Hendricks, & Stuit Insurance Agency, Inc. :: Client Services :: Business Services

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Client Services :: Business Services :: Policy Change Request

Please note: We cannot bind coverage from an email or voicemail request. Coverage is bound after you receive a written email or telephone confirmation from an agency staff member within 24 hours.

Contact Information
Effective date of change:
Name:
Enter your phone number (if you would prefer us to contact you by phone):	Ext:
Enter your email address (Required):

Change Your Commercial Auto Policy
Add or Delete a Driver Add a Driver Delete a Driver
First Name:
Middle Name:
Last Name:
Date of Birth:
Gender Male Female
Social Security Number:
Drivers License Number:
State Issued:
Add or Delete a Vehicle
Add a Vehicle Delete a Vehicle
Make:
Model:
Year:
VIN:
Cost, New:
Titleholder/leaseholder:
Lien Holder Information
Name:
Address:
City, State, Zip:
Gross Vehicle Weight:
Vehicle Use:
Additional modifications to the vehicle
Garaged: Yes No
If Garaged:
Location:
Address:
City, State, Zip:

General Policy Change
Policy Type: Commercial Property/Casualty Commercial Auto Workers Compensation Other:
Description of Change:
Inquiry or Additional Comments:
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