Tanenbaum Harber

Request to 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 Tanenbaum Harber 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)