Add or Delete A Loss Payee

Insured's Name

Policy Number:
 		Effective Date of Change:
Add Delete
Certificate Holder: Additional Insured Loss Payee

Loss Payee's Name, Address & Loan Number if Required:

Name
Street or P.O. Box
City
State
Zip
Phone
Fax Number
Loan Number if Applicable

If Adding a Loss Payee, indicate if for Business,
Personal Property or Equipment:

Business Personal Property

Equipment

If Equipment, Describe Indicating Serial Numbers and Value to Insure:

Year:
 		Make:
 		Model:
 		Serial #:
 		Value:

Comments:

Requested By: Date
E-Mail:

No Coverage may be added, changed, or bound as a result of submitting this request. All coverage must be confirmed by Miller & Associates in writing, either via email or fax. If you do not receive a response from us within three working days, please call or email to confirm receipt of request.
I have read and agree with the above disclaimer (It is mandatory to check box before request can be sent)

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