Hennessey, Thames, & Leavitt

Modify Property Coverage

Policyholder Name:
Name of Individual requesting change:
Email Address:
Modification:		Add Change Delete
Address of property:
Type of property:	Building	Amount of Coverage:
	Home	Amount of Coverage:
	Contents	Amount of Coverage:
Deductible amount:		$
If you are adding, or moving to, a new location, please complete the following information:
Year Built:
Construction Type:
Square footage:
Contact Person:
Contact Phone Number:

I understand that completing and sending this form does not bind coverage changes.
Please note: This is an alternative method for communicating with us. We will contact you as soon as possible.

	October 11, 2008