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RPG Policy Change/Certicate Request Form
1. Complete all sections (print legibly)
2. Remit completed request form to us
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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 • CA #0334819
Please retain a copy of this form for your records.
Today’s date: _______/_______/_______
Effective date of change: _______/_______/_______
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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: _________________________________________
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Submit change request submission to us.
E-mail: • Fax: 1-260-459-5995
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.
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: ________________________________________________________________
Please explain/describe change: __________________________________________________________________
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: _______________________________________________________________
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