Structure Change Form

Name Insured(Required)

Date(Required)

Policy #(Required)

Completed By:(Required)

Type of Property(Required)

Project #

Unit Number

Building Description

Building Occupancy

Physical Address (As shown in policy declarations)(Required)

Street Address City State / Province / Region ZIP / Postal Code

Type of Change(Required)

1-4 Residential Property Change

Commercial Change

Project #

Unit #

Occupant Name

First Last

Building Description

Building Occupancy

Square Footage(Required)

Exterior Type/Siding(Required)

Other, type of siding

Construction Type(Required)

Other Construction Type

Roof Type(Required)

Other Roof Type

Year Built(Required)

Other Notes about structure

Physical Address(Required)

Street Address City State / Province / Region ZIP / Postal Code

***Please note your changes will be endorsed the day your request is received in our office.***

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Name

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