* Should you have any questions or any doubt about a change you are contemplating, please call our office during working hours for advice and/or guidance.

    I/We wish to make the following changes to my/our insurance policy as indicated below:

    I/We instruct M.R. Banas Insurance Agency, Inc. D/B/A Banas & Fickert Insurance Agency to make the change(s) filled in above to my/our above listed insurance policy
    My/Our above requests have been carefully reviewed and selected and I/we understand my/our changes with no questions whatsoever. Please be advised that no coverage can be bound nor any changes made to your policy until confirmed in writing by an employee during regular business hours. If you have not heard from us within 24 hrs (not including weekends & holidays), please let us know as we may not have received your information.

    I Agree to the Terms above*