Fillable 1454 RPG Policy Chg 3-13 (K&K Insurance Group)

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1454 RPG Policy Chg 3-13 (K&K Insurance Group)

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  • 48 check-boxes
  • 110 other fields

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Page 1 of 3
RPG Policy Change/Certicate Request Form
GENERAL
INFORMATION
TO AVOID PROCESSING DELAYS, PLEASE:
1. Complete all sections (print legibly)
2. Remit completed request form to us
GENERAL REQUESTS
1454 3/13
Named insured (as it appears on your certicate of insurance): ___________________________________________
Policy number (as it appears on your certicate of insurance): ____________________________________________
Contact name: ____________________________________ Phone: (______) _____________________________
Cell: (______) ___________________________________ Fax: (______) __________________________________
E-mail: ________________________________________
Please indicate the type of change needed and complete the appropriate section.
Note: Some changes may result in an increase of premium due and will be effective the day after receipt or a later date.
m Cancel coverage m Limit of coverage
m Cancel/change event date m Mailing address
m Certicate amendments and/or requests m Named insured
m Contact name m Phone, fax and/or e-mail
m Facility location m Type of operation
m Other (please explain): _______________________________________________________________________
Cancel Coverage
Effective date of cancellation: _______ / _______ / _______ (Note: coverage can not be cancelled prior to our receipt of this form)
Reason for cancellation: ________________________________________________________________________
Cancel/Change Event Date
Effective date of cancellation/change: _______ / ______ / _______ (Note: request must be received prior to or on the day of event)
Reason for cancellation/change: __________________________________________________________________
Facility Location Change
m Replace facility location m Add new facility location
Address: ____________________________________________________________________________________
City: ________________________________________________________State: ______ Zip: _________________
New facility square footage: ___________________
Was there a change in the insured’s annual sales?
m Yes m No
If yes, please provide revised annual sales: $____________
Did membership change?
m Yes m No
If yes, please provide revised membership number:_______________
Do you currently have Sexual Abuse or Sexual Molestation Liability Coverage with us?
m Yes m No
K&K Insurance Group, Inc. • P.O. Box 2338 • Fort Wayne, IN 46801-2338 • 1-800-637-4757 • Fax 1-260-459-5995
www.kandkinsurance.com • CA #0334819
Please retain a copy of this form for your records.
Today’s date: _______/_______/_______
Effective date of change: _______/_______/_______
Page 2 of 3
FOR K&K
USE ONLY
Rec:_____/_____/_____ Policy #: _______________ Cert #: ______________ Insured #: _______________
Quote: _____/_____/_____ Bound: _____/_____/_____ Opt:____________ Premium: $______________
Eff/Exp: _____/_____/_____ to _____/_____/_____ Opt form: 2026 2011 2404 8016 8018 876
Delivery: M F E Date: _____/_____/_____ Comments: _________________________________________
1454 3/13
GENERAL REQUESTS CONTINUED
MAILING
INSTRUCTIONS
Submit change request submission to us.
 • E-mail:KK_MassMerchandising@kandkinsurance.com•Fax:1-260-459-5995
 • Mail
  Regular: K&KInsuranceGroup,Inc. Overnight: K&KInsuranceGroup,Inc.
  MMRPGPrograms MMRPGPrograms
  P.O.
Box2338,FortWayne,IN46801-2338 1712MagnavoxWay,FortWayne,IN46804
Note: Ifacerticateofinsuranceisneededforthischangerequest,pleaseproceedtopage3andincludethis
with the change request submission.
(
DOCUMENT
DELIVERY
This coverage document will be delivered via e-mail, unless otherwise indicated below. If you have an insurance
agent, all documents will be delivered to your agent only. Additional certicate requests will be issued to the same
person. Please select only one option.
m E-mail to: ______________________________________ attn: __________________________________
(selecting this option conrms your consent for coverage documents to be delivered via e-mail)
m Fax to: ______________________________________ attn: __________________________________
m Mail to: ______________________________________ attn: __________________________________
______________________________________
Limit of Coverage
Typeofcoverage:________________________________________________________________________________________
Currentlimit:$_______________________________
Newlimitrequested:$_______________________
Do you currently have Sexual Abuse or Sexual Molestation Liability Coverage with us?
m Yes m No
Named Insured, Contact Name, Mailing Address, Phone, Fax or E-mail Change
Namedinsured: _________________________________________________________________________________________
Mailingaddress:_________________________________________________________________________________________
City:___________________________________________________ State:_____________Zip:_____________________
Contactname: __________________________________________ E-mail: _______________________________________
Phone:(______)__________________________________________ Fax:(______)__________________________________
Type of Operation
Pleaseprovidethetypeofchange: ________________________________________________________________________
________________________________________________________________________________________________________
Other
Pleaseexplain/describechange:__________________________________________________________________________
________________________________________________________________________________________________________
CERTIFICATE REQUEST
Complete this section to request a new certicate.
Provideseparaterequestsforeachadditionalcerticateneeded.
This is a
m Change/amendmenttoacerticatealreadyissued(pleaseattachacopyofthecerticate)
m Newcerticaterequest
Needbydateforcerticate:_______/_______/_______
Thiscerticateisforour:
m Programcoverage(commercialgeneralliability) m Equipmentandcontentscoverage
Checkthetypeofcerticateyouarerequesting:
m Additionalinsured m Evidenceofcoverage m Losspayee
Certicateholderinformation:
Entityname:__________________________________________________________________________________
Mailingaddress:______________________________________________________________________________
City:______________________________________________State:_____________Zip:_________________
Relationshiptonamedinsured:
m Owner/lessorofpremises mSponsor m Co-promoter m Mortgagee
m Franchisor mLessorofequipmentandcontents mEventorganizer
m Other(pleaseidentify/explain):____________________________________________________________
Special
certicatelanguageneeded(pleaseexplain/attach):____________________________________________
m Primary m Waiverofsubrogation m Cancellation-_________days
Ifapplicable:
RE: Date(s)ofevent/activity:_______/_______/_______to_______/_______/_______
Hoursoftheevent/activity:_________A.M./P.M.to_________A.M./P.M.
Typeofevent/activity:_________________________________________________________________________
Nameofevent/activity:________________________________________________________________________
Locationofevent/activity:_____________________________________________________________________
Page 3 of 3
1454 3/13
PAYMENT INFORMATION
100% of the premium is due upon receipt of this supplemental.
m Check:PleasemakecheckpayabletoK&KInsuranceGroup,Inc.Enclosedischeck#_______for$ __________
m Credit Card:Ifyouaremakingyourpaymentbycredit/debitcard,pleasecompletethefollowing:
mVISAmMASTERCARD mDISCOVER mAMERICANEXPRESS
Card
number:_______________________________________________________________________________________
CSC#(cardsecurity)code:_______________________Expirationdate:_____________________________________
I
authorizeK&KInsuranceGroup,Inc.tochargemypaymenttomycreditcardintheamountof$_____________
Print name (asoncard):______________________________________________________________________________
Cardholder signature: ______________________________________________________________________________
Copyright©2013K&KInsuranceGroup,Inc.AllRightsReserved.
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1454 RPG Policy Chg 3-13 (K&K Insurance Group)

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Completed 15 July 2020

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