Underwriting Service Request Form – Auto/WC

Underwriting Service Request Form - Auto/WC

A separate form is used for Auto/WC New Business quote requests: click here

(If binding new Auto/WC business, please reply to the quote email instead of using this form. For the package, our core insurance program, please submit your request via Origami.)

Agent/Agency Name(Required)

Other Agent/Agency(Required)

Your Name(Required)

Your Email Address(Required)

Enter only one valid email address. A copy of the submission will be sent to this email address.

Participant/Church IB#(Required)

Current participants only. Use New Business form or email for prospects. Please enter IB# as shown on the MOI without "PK" policy #.

Participant/Church Name(Required)

As shown on the MOI.

Participant/Church City(Required)

Participant/Church State(Required)

Participant Zip Code(Required)

Participant/Church Email Address

For Loss Control Resources.

Auto/WC Policy #(Required)

Effective Date of Requested Change(Required)

If not applicable, enter need by date.

Need By Date

If left blank, normal turnaround times apply; 30 business days.

Is this a Rush Request?(Required)

Yes

If less than 30 business days, requests will be treated as rushes ONLY IF a reason for the rush is described below and a need by date is provided.

Details & Description of Request(Required)

Upload Additional Documentation (optional)

Drop files here or

Max. file size: 50 MB.

Do not send copies of driver's license if adding a new driver.

Additional Comments or Instructions

Are you Requesting to Add a New Driver?(Required)

Yes

New Driver - Name(Required)

As it appears on Driver's License.

New Driver - Driver's License #(Required)

As it appears on Driver's License.

New Driver - Date of Birth(Required)

As it appears on Driver's License.

New Driver - Driver's License State(Required)

As it appears on Driver's License.

Name

This field is for validation purposes and should be left unchanged.