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Policyholder Policy Request Form
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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
Full 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 Number:   )  For internal purposes only
 
Depending on the change that you requested, we may  need to contact you for additional information. Please  select your preferred method of contact:  Daytime Telephone  Listed above
E-Mail Address
  If different from E-mail listed above:
Please select the best time to reach you: 
 
Please select the type of policy copy you need from the options listed below:
 
 
 
Request for Evidence of Insurance
Please select the option that applies to you: 
Send a copy of the policy to the Mortgagee/Loan Company that currently appears on the Declarations page.
Send a copy of the policy to the Mortgagee/Loan Company that I list below:
Name of Mortgagee/Loan Company: 
Contact Name: 
Mailing Address: 
City: 
State: 
Zip Code:   - 
I have indicated a new Mortgagee/Loan 
Company because (please select one)
The Mortgagee/Loan Company on the policy is being replaced with a different loan company. The original mortgage company is no longer financing the loan for the insured property.
The Mortgagee/Loan Company for which I am requesting evidence of insurance is now an additional lienholder for the property. (Note: the Mortgagee/Loan Company listed on the policy remains on the policy. Please add an additional Mortgagee/Loan Company on the property.)
Which method should we use to send the policy  copy to the Mortgagee/Loan Company?  Fax: ( )
First Class Mail
Fax/Mail Policy Copy to the Attention Of: 
 
Do you need to make additional requests before you submit your form?
 
 
 
Request for Copy of Declarations Page or a Copy of the Complete Policy
Please select the option that applies to you: 
I need a copy of the declarations page only.
I need a copy of the complete policy (includes declarations page, policy and all endorsements).
Which method should we use to send 
the policy copy to you? 
Fax: ( )
First Class Mail
Fax/Mail Policy Copy to the Attention Of: 
 
Do you need to make additional requests before you submit your form?
 
 
 
 
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 27, 2003