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Welcome to Borden Perlman
Phone
1-609-482-2207
Fax
1-609-895-1468
Claims
1-800-237-2917
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Ask us a Question/E-mail
Policy Change Request Form
* fields are mandatory
Current Information
*
Named insured (as it appears on your certificate of insurance):
*
Policy number (as it appears on your certificate of insurance):
*
Contact first name:
*
Contact last name:
Effective date of change(s):
Please enter the correct date format (mm/dd/yyyy).
That date entered must be today’s date or later.
*
Phone:
Cell:
*
E-Mail:
Please indicate the type of change needed and complete the appropriate section
Cancel coverage
Limit of coverage
Cancel/change event date
Mailing address
Certificate amendments and/or requests
Named insured
Contact name
Phone, fax and/or e-mail
Facility location
Type of operation
Other (please explain)
Please select
Please enter field
Note:
Some changes may result in an increase of premium due and will be effective the day after receipt or a later date.
Cancel Coverage
*Effective date of cancellation:
Please enter field
The date entered must be tomorrow’s date or later.
Please enter the correct date format (mm/dd/yyyy).
*Reason for cancellation: (
Refund Policy
)
Please enter field
Note:
Coverage cannot be cancelled prior to K&K's receipt of this form.
Change Limit of Coverage
(an increase in liability limits will result in additional premium due)
*Type of coverage:
Please enter field
*Current liability limit:
*New limit requested:
Please enter field
Please enter field
Cancel/Change Event Date
*Effective date of cancellation/change:
Please enter field
The date entered must be tomorrow’s date or later.
Please enter the correct date format (mm/dd/yyyy).
*Reason for cancellation/change: (
Refund Policy
)
Please enter field
Note:
Request must be received by K&K prior to day of event.
Named Insured, Contact Name, Mailing Address, Fax or E-mail Change Information
Only enter the fields to be changed.
*Named insured:
Please enter field
*Mailing address:
Please enter field
*City:
Please enter field
*State:
Select
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Please select
*Zip:
Please enter field
The information you entered is invalid, please try again.
*Contact first name:
*Contact last name:
Please enter field
Please enter field
E-mail:
Cell:
Please enter field
Invalid email ID entered.
The information you entered is invalid, please try again.
Please enter field
Phone number:
Fax:
The information you entered is invalid, please try again.
The information you entered is invalid, please try again.
Please enter field
Please enter information for at least one change or change the type of change above.
Request Certificate
*Type of request:
Please select
Change/amendment request to a certificate already issued
New certificate request
Certificate of insurance request
*This certificate is for our:
Please select
Program coverage (commercial general liability)
Equipments & contents coverage
*Check the type of certificate you are requesting:
(what's this?)
Please select
Additional insured
Evidence of coverage
Loss payee (Inland Marine/Equipments & Contents)
Certificate holder information
*
Entity name (as it should appear in the certificate):
*
Mailing address:
*
City:
*
State:
Select
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
*
Zip
*Relationship to insured entity:
Please select
Owner/lessor of premises
Sponsor
Co-promoter
Mortgagee
Franchisor
Event Organizer
Lessor of Equipments and Contents
Other (please identify/explain)
Please enter field
If applicable
Dates of events/activity:
From
To
Please enter the correct date format (mm/dd/yyyy).
Please enter the correct date format (mm/dd/yyyy).
Hours of events/activity:
From
HH
1
2
3
4
5
6
7
8
9
10
11
12
MM
00
15
30
45
AM
PM
To
HH
1
2
3
4
5
6
7
8
9
10
11
12
MM
00
15
30
45
AM
PM
Types of events/activity:
Name of events/activity:
Location of events/activity:
Need by date:
Please enter the correct date format (mm/dd/yyyy).
Special certificate language needed (please explain):
Add Another Certificate
Information
Do you want to delete the record?
Facility Location Change
*Select:
Replacement facility location
Additional facility location
Delete facility location
*Mailing address:
Please enter field
*City:
Please enter field
*State:
Select
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Please select
*Zip:
Please enter field
The information you entered is invalid, please try again.
*New facility square footage:
sq. ft.
Please enter field
*Was there a change in the insured's annual sales?
Yes
No
*Provide the new annual sales:
$
Please enter field
*Is there a change in total number of members?
Yes
No
*Provide new total number of members:
Please enter field
Type of Operation
*Please provide the type of change:
Please enter field
Other
*Please explain/describe change:
Please enter field
Document Delivery
This certificate will be delivered based on the option you indicate below.
Please select
E-mail to:
Attn:
Invalid email ID entered.
Please enter field
Fax to:
Attn:
The information you entered is invalid, please try again.
Please enter field
Mail to:
Attn:
Mailing address:
Please enter field
City:
Please enter field
State:
Select
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Please select
Zip:
The information you entered is invalid, please try again.
Please enter field
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