Change Request Form

Make changes to your existing insurance policies with the PCALIC QUICK CHANGE FORM below. Any change in ownership will require speaking to a representative of PCALIC and may not be completed by using the QUICK CHANGE FORM.

MOVED TO A NEW LOCATION

Mailing Address
Physical Address

Insured Name:*
Policy Number:

Address of premises to be removed
Street:
City:
Zip:
Telephone Number:

Address of premises to be added
Street:
City:
Zip:
Telephone Number:

NEW PREMISES COVERAGE:

Amount of Coverage
Building Limit:
Contents Limit:
Business interruption Limit:
Extra Expense Limit:

NEW BUILDING EXPOSURES:

What is the construction:
Is a fire hydrant within 1000 feet?
Is a fire company within 3 miles?
Is there a sprinkler system?
Do you have a fire alarm?
Is Fire alarm to central station?
What is square foot of building?
How many stories is the building?
What year was building built?
Are there any other occupants?

NEW BUILDING USE:

Is the building owner occuppied?
What is the Cupancy of the Building?

ADDING OR DELETING A MORTGAGE TO A BUILDING

Name:
Street:
City:
State:
Zip:
Telephone Number:
Fax Number:
Contact:


	MEMBERS ONLY Username Password


	PCALIC ON THE WEB

Adult Residential Care Facilities are in good hands with PCALIC, not just for insurance, but also for vital educational materials we receive from them that enhances staff training and program evaluations. We thank you!

- MILLER & SON PCH, INC.

Change Request Form

MOVED TO A NEW LOCATION

NEW PREMISES COVERAGE:

NEW BUILDING EXPOSURES:

NEW BUILDING USE:

ADDING OR DELETING A MORTGAGE TO A BUILDING

MEMBERS ONLY

PCALIC ON THE WEB

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