Homeowners Insurance Policy Coverage Change Form

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

Policy Number*

1.) Change deductible to:
—Please choose an option—$500$1,000$2,500

(If you want to know the exact premium reduction from any change you maybe contemplating, please call our office for the exact premium savings.)

2.) Change Dwelling/Coverage A, please increase to: $

(In order for us to increase this limit, you must have spoken previously to our office within the last 30 days and completed an updated dwelling replacement cost estimator.)

3.) Change Personal Liability, Each Occurrence, please increase to:
—Please choose an option—$500,000$1,000,000

The maximum limit available is $1 Million per occurrence; on Mass Property Insurance Underwriting Association policies the maximum is $500,000. Higher limits are available from an additional $1 Million up to $10 Million + with a Personal Umbrella policy. A Personal Umbrella policy will cover your premises and auto(s). To request an umbrella policy quote, please call our office or access our quote section on our web page.

Add Identity Theft coverage:
YESNO

Add Earthquake coverage:
YESNO

Add Sewer Back up/sump overflow coverage:
YESNO

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*

Date:*

Your Email*

Your name(s):*

Daytime Phone Number (include area code):*