American Modern Insurance - Home American Modern Insurance Group
Policyholder Name or Address Change Form
Click Here for more information on SSL     
 
Instructions for Submitting this Form to the American Modern Insurance Group:

Clicking on the Submit button on the last page of this form will electronically send your information to the American Modern Insurance Group. However, you also have the option of printing the form and faxing or mailing the page(s) to us.

Clicking on the Print button will not submit your information to us. Instead, it will take you to a print friendly page with all your information listed. You can then print that page and fax or mail the form to us. The print friendly page will also include the address or fax number you will need to use to send us claim information.

Note: These instructions will be repeated at the bottom of the form before you submit or create the print friendly page.

Fields marked with a * are required for submission.
 
Personal Information
First and Last Name(s):  * As on policy
Policy Number:  * Requires 13 characters
Date of Birth:  * For verification purposes
E-Mail Address:  For internal purposes only
Daytime Telephone:    (   )   Ext. For internal purposes only
Save Information:  Click here to save the above information for future use.
 
Depending upon the change that you request, we  may need to contact you for additional information.  Please select your preferred method of contact:  Daytime Telephone
E-Mail Address (if not listed above):
Please select the best time to reach you: 
 

This form allows you to make a change to your name, mailing, or physical address noted on your policy. If you need to make a change that is not listed, such as additions or deletions to the policy coverage, please contact Customer Care at 1-800-543-2644.

 

 
Name Change Information
Type the change EXACTLY as it should appear on the policy.
 
First and Last Name(s): 
Reason for Change: 
Marriage Divorce
Widowed or widower Sold Property
Other (describe in Comments)
Comments: 
 
 
Mailing Address Change (where you want your mail delivered)
Type the change EXACTLY as it should appear on the policy.
 
New Street Address: 
P.O. Box: 
Physical Address:  Required with a P.O. Box
City: 
State: 
Zip Code:   - 
 
 
Physical Address Change (where the insured property is physically located)
Type the change EXACTLY as it should appear on the policy.
 
New Street Address: 
City: 
State: 
Zip Code:   - 
 
 
 
Form Options
Instructions for Submitting this Form to the American Modern Insurance Group:

Clicking on the Submit button below will electronically send your information to the American Modern Insurance Group. However, you also have the option of printing the form and faxing or mailing the page(s) to us.

Clicking on the Print button will not submit your information to us. Instead, it will take you to a print friendly page with all your information listed. You can then print that page and fax or mail the form to us. The print friendly page will also include the address or fax number you will need to use to send us claim information.

Since you will still have the ability to electronically Submit your form to us on the print friendly page, you may want to use the Print option before you submit. Click the Print button below first, then print a copy of the next page for your records. Lastly, click on the Submit button at the bottom of the print friendly page to send the completed form to the American Modern Insurance Group.
 

        
 
 
 
Last Updated on March 20, 2003