Disclaimer: I understand that this
request for service DOES NOT constitute ANY CHANGE to my
policy, but is rather a submission of information to the
agency for an representative to call in reference to this
submission. (you should receive a fax confirmation for any
change to take effect) There is no obligation on our
part to make any changes ver. an internet submission.
This submission does not constitute a statement or contract
for insurance, or bind coverage.
I have read and understand and agree with the above
disclaimer. Box must be checked before request
any consideration will be given to the form!)