Policy Change | Panhandle Farmers Mutual Insurance Company

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Fields marked with an * are required

Insured Name *

Agent Name *

Person Completing Form *

Phone *

Email *

Date Completed *

Policy Number *

Requested Effective Date for Change *

Change Name of Insured to

Reason for Change

This cannot be used to transfer a policy from one person to the other. This is to change a name of an existing insured for reasons resulting from marriage, divorce, etc.

Add Structure to Existing Policy

Request Change to Policy Limits

Mortgage Changes

Mortgage to

Replacement Cost Contents (Cost is $1.50 per $1,000 of Coverage C per year)

Refrigerated Foods (Cost is $15.00 Per Year)

Additional Insured (Cost is $10.00 per Additional Insured)

Name and Address of Insured

Add Garage or Other Outbuilding

Amount of Coverage

ATV or Farm Machinery Coverage (Limited to Physical Damage Only)

Make / Model / Year / Serial Number / Amount of Coverage

Add Liability to the Policy

Extend Liability to another location:

Address of the property

Policy Needs Cancelled

Reasons for Cancellation

Remarks or special instructions pertaining to any of the information above

File Attachment

This form is not to be used to transfer an insurance policy from one person to another nor to transfer a policy currently in force to another property location. A new application is required to accomplish either of these transactions. Contact must be made with your agent for this type of transaction.

Disclaimer: The change requested will not be effective until approved by underwriting. You will receive a new declaration page noting the change once approval has been granted. If you need coverage bound immediately, contact should be made directly with your agent. We will notify the agent of changes requesting an increase in coverage to obtain the proper photos and other information that may be necessary to evaluate and process this request.

I hereby certify that I have the authority to make this request by being the insured or a representative of the insured. *

Signature of Insured/Person completing form

Your Email *