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.)

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

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.

Underwriting Service Request Form - Auto/WC

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