Risk Management Property Change Form First Name of Requester * Last Name of Requester * Requester Email Address * County/Entity Name * Effective Date of Change * Building Details Choose One * Add Delete Change Building Name * Building Physical/Street Address * Building Physical/Street Address Building Physical/Street Address Building Physical/Street Address City City State/Province State/Province Zip/Postal Zip/Postal Number of Employees in Building * Construction of the Building * Square Footage * New or Existing * New Existing Is this a new building to be added or an existing building already insured? Occupancy Building Replacement Value * If there is not a value for a required field, please input "0." Contents Replacement Value * If there is not a value for a required field, please input "0." Property in the Open * Is this location in a flood zone? * Yes No Is there a mortgagee on the property? Yes No Contract or Mortgage number Bank/Financial Institution (as it should appear on the certificate) Mailing Address Mailing Address Mailing Address Mailing Address City City State/Province State/Province Zip/Postal Zip/Postal Email Fax Number A Certificate of Insurance (COI) is used to notify a third party (not the member) that coverage is in place for specified circumstances. Must note the name of the Certificate Holder (the third party) requesting the COI, if they have an interest in the property (Loss Payee), and what are the circumstances requiring the COI. Special Instructions More Information For more information contact Underwriting at (919) 719-1170 or email [email protected]. Enter email address to receive an email copy of this form If you are human, leave this field blank. Submit
