Endorsements — INSURHAUS

STEP 1 OF 8

Change request

This form is used to request change of the policy for transportation risks

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This field is for validation purposes and should be left unchanged.
Customer Information
Insured's / Certificate code of the Customer*
The code is unique for every customer, if you don't have your customer code, please call to INSURHAUS at 630-678-9971 to obtain it. If the code won't match the customer name, request won't be processed.
Accept customer name?*
- Yes
- No
You did not accept given Customer Name. Do you want to make a correction?*
- Request customer name correction
Customer name*
Customer name must match the named insured's name on a policy
Customer Email*
Customer Phone*
Requesting the change person info
Name*
First Last
Email
Phone
Type of Coverage*
- Personal
- Commercial
Effective date of change*
MM slash DD slash YYYY

All changes will be done with the same effective date, if you require different dates to be effective, please create separate requests for every change. Common practice is that change is not backdated, if you require the change call your agent to find out is it possible, All change requests with effective date - TODAY will be processed tomorrow if received after 3pm CST.

Add Vehicle(s)
In this section we will add your trucks and trailers if you have them. To do that, click the Add a Vehicle button below, complete the required fields and then click the Save Vehicle button.
If you need to make changes to an existing vehicle, click the edit button or delete button to delete the vehicle and start over.
Vin Year Make Model Value Owned by
Please make sure that information is correct. Value must be entered only if Physical damage is required for the vehicle. If the Value is entered, this vehicle will be added to PD automatically Owned by must reflect owner of title.
Please make sure that information is correct. Value must be entered only if Physical damage is required for the vehicle. If the Value is entered, this vehicle will be added to PD automatically Owned by must reflect owner of title.
Delete Vehicle(s)
In this section we will add your trucks and trailers if you have them. To do that, click the Add a Vehicle button below, complete the required fields and then click the Save Vehicle button.
If you need to make changes to an existing vehicle, click the edit button or delete button to delete the vehicle and start over.
Vin Year Make Model Reason for deletion
Please make sure that information is correct. Please provide reason for deletion and upload required documents. You can fax documents to us by fax 630-495-6039
Please make sure that information is correct. Please provide reason for deletion and upload required documents. You can fax documents to us by fax 630-495-6039
Add Driver(s)
In this section we will add your drivers if you have them. To do that, click the Add a Driver button below, complete the required fields and then click the Save Driver button.
If you need to make changes to an existing driver, click the edit button or delete button to delete the driver and start over.
Name DL number Date of Birth State Licensed
All fields are required, no change will be processed if information won't be provided in full. Policy terms define requirements for drivers, but common requirements are that driver would have CDL for more than 2 years. DL - Driver's License DOB - Date of Birth State Licensed - State where driver license issued.
All fields are required, no change will be processed if information won't be provided in full. Policy terms define requirements for drivers, but common requirements are that driver would have CDL for more than 2 years.
DL - Driver's License
DOB - Date of Birth
State Licensed - State where driver license issued.
Delete Driver(s)
In this section we will add your drivers if you have them. To do that, click the Add a Driver button below, complete the required fields and then click the Save Driver button.
If you need to make changes to an existing driver, click the edit button or delete button to delete the driver and start over.
Name DL number Date of Birth State
All fields are required, no change will be processed if information won't be provided in full. DL - Driver's License DOB - Date of Birth State Licensed - State where driver license issued.
All fields are required, no change will be processed if information won't be provided in full.
DL - Driver's License
DOB - Date of Birth
State Licensed - State where driver license issued.

Financial details
Account/Credit card Holder full name*
Billing Address*
Street Address Address Line 2 City State ZIP Code
Bank account / Credit card number*
Bank routing number*
Expiration Date (mm/yyyy)*
Card Security Code*
Billing Phone*
Please read and agree by entering your name and signing
By entering name below, I'm signing ACH form for multiple charges and authorize AGENSTHAUS/INSURHAUS INC to charge the bank account indicated above for any charges related to coverage/policies issued and managed by Agentshaus/INSURHAUS for named insured/client defined above unless alternative payment information is provided upon enrollment. These charges may include, but are not limited to, down payments, recurring monthly payments, endorsement payments, taxes and fees incurred in relation to any insurance coverage written trough AGENTSHAUS/INSURHAUS. This form also applies to any risk or coverage submitted by named insured to cover third party. I understand that this authorization will remain in effect until I cancel it in writing, and I agree to notify INSURHAUS INC in writing of any changes in my account information or termination of this authorization at least 15 days prior to the next billing date. If the payment dates fall on a weekend or holiday, I understand that the payment may be executed on the next business day. I understand that because this is an electronic transaction, these funds may be withdrawn from my account as soon as coverage is requested. In the case of an ACH Transaction being rejected for Non Sufficient Funds (NSF) I understand that INSURHAUS INC may at its discretion attempt to process the charge again within 30 days, and agree to an additional $35.00 charge for each attempt returned NSF which will be initiated as a separate transaction from the authorized payment. I acknowledge that the origination of ACH transactions to my account must comply with the provisions of U.S. law. I agree not to dispute this recurring billing with my bank so long as the transactions correspond to the terms indicated in this authorization form.
Please read and agree by entering your name and signing
By entering name below, I'm signing form for one time charges and authorize AGENSTHAUS/INSURHAUS INC to charge the bank account / credit card indicated above for any charges related to coverage/policies requested by me filling this form for named insured/client defined above. These charges may include, but are not limited to, down payments, endorsement payments, taxes and fees incurred in relation to change requested. This form also applies to any risk or coverage submitted by named insured to cover third party. I understand that this authorization will remain in effect until all charges for requested change will be applied, and I agree to notify INSURHAUS INC in writing of any changes in my account information or termination of this authorization at least 15 days prior to the next billing date. If the payment dates fall on a weekend or holiday, I understand that the payment may be executed on the next business day. I understand that because this is an electronic transaction, these funds may be withdrawn from my account as soon as coverage is requested. In the case of an ACH Transaction being rejected for Non Sufficient Funds (NSF) I understand that INSURHAUS INC may at its discretion attempt to process the charge again within 30 days, and agree to an additional $35.00 charge for each attempt returned NSF which will be initiated as a separate transaction from the authorized payment. I acknowledge that the origination of ACH transactions to my account must comply with the provisions of U.S. law. I agree not to dispute this billing with my bank so long as the transactions correspond to the terms indicated in this authorization form.
Name of authorized representative*
First Last
Please sign*
Click here to Sign

Sign above
- Use this signature to sign this change request
Compliance statement
By the signing of this application, I hereby declare that the statements and particulars given on this form are true to the best of my knowledge and belief and that I have not suppressed, withheld or modified any material facts. I agree that should a coverage be changed, this form shall be the basis of the contact, and that any change in pattern or my trade or trade practices shall be advised to the Underwriters who may at their discretion, vary the terms and conditions of this contract. I agree that submitting this form brings obligation to pay for changes requested.
*
- I agree with the statement above by entering name above and signing

Personal

Business

Change request

Customer Information

Requesting the change person info

Select Coverages

Choose Actions

Add Vehicle(s)

Delete Vehicle(s)

Add Driver(s)

Delete Driver(s)

Payment Details

Financial details

Please read and agree by entering your name and signing

Please read and agree by entering your name and signing

Compliance statement

Compliance statement