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Quick Change Form

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.

ADD OR CHANGE A LOCATION

Add or change location

Insured's First Name*

Insured's Last Name*

Policy Number

Address of premises to be removed

Street

City

Zipcode

Telephone Number

Address of premises to be added

Street

City

Zipcode

Telephone Number

New Building Exposures

Building Limit

Contents Limit

Business Interruption Limit

Extra Expenses

double click to edit

What is the construction

Is a fire hydrant within 1000ft?

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 the building built

New Building Use

Is the building owner occupied?

What is the occupancy of the building?

Adding or deleting a mortgage to a building

Name

Street

City

State

Zipcode

Telephone Number

Fax Number

Does the mortgage holder need to be listed?

What is the loan number?

Is the Loan escrowed for this location/building

No change is effective or confirmed until you have received evidence of insurance acknowledging the change. If you do not receive evidence of insurance acknowledging this change, please contact your representative at PCALIC at 800-673-2558 to make the change and obtain evidence of insurance acknowledging the change.

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