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Please fill out the following Commercial Property/Equipment Change Request form. Please note that any changes will NOT be in effect until you receive confirmation from our office.

*Required Fields

Property/Equipment Change Request Form

Insured Information

*Name  

Address  

City  

State  

Zip  

*Email  

*Phone  

 

Type of Change

*Change Type  

Property/Equipment Information

Property/Equipment   Address  

Property/Equipment   City  

Property/Equipment   State  

Property/Equipment   Zip  

Description of Property/Equipment

Property/Equipment   Value  

Loss Payee Information

Name  

Address  

City  

State  

Zip  

 

 
 
 
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Scott Umland Insurance Services, LLC

2028 Jackson Street

P. O. Box 236

New Holstein, WI 53061

Phone: (920) 898-5755