KBS Change Request Questionnaire

1.  Effective Date of Change:

2.  Policyholder and Contact Information:
     Company Name of Policyholder:
     Name of Person Requesting Change:
     Title of Person Requesting Change:
     Name of Person to Contact for More Info:  Check box if same as above
     
     Title of Person to Contact for More Info:     Check box if same as above
     
     Contact Phone Number:    Ext.   
     Contact Fax Number:
     Contact E-mail Address:

3.  Type of Change:    Select Box and Click on Field of your choice to Proceed

         Name, Type of Entity

         Nature of Business / Operations

         Address, Location

         Property Values

         Auto - Vehicle

         Other

Name/Entity Change:  you may make one or two changes

1.    Name One:
       Type of Entity (select one):  Corporation LLC Partnership Sole Proprietorship Trade Name (dba)
       Instructions:
       Add / New Change Delete Type of Entity Change Only
 
  
       If new, at least 50% shared ownership with current policyholder?
           YES   NO

2.    Name Two:
       Type of Entity (select one):  Corporation LLC Partnership Sole Proprietorship Trade Name (dba)
       Instructions:
       Add / New Change Delete Type of Entity Change Only
   

       If new, at least 50% shared ownership with current policyholder?
           YES   NO

3.    Additional Instructions or Comments?   
            

       Finished - Ready to Submit             Select Another Type of Change

Nature of Business / Operations Change: 

1.    Describe Business Operations: 
      

       Instructions:
       Add / New Delete
 
       Location(s) of Ops:

       Estimated Annual Payroll related to operation: $

       If new, describe safety and loss control practices being implemented:
      

2.    Describe Business Operations: 
        

       Instructions:
       Add / New Delete
 
       Location(s) of Ops:  

       Estimated Annual Payroll related to operation: $

       If new, describe safety and loss control practices being implemented:
      

3.    Additional Instructions or Comments?   
            

       Finished - Ready to Submit             Select Another Type of Change

Address / Location Change:

1.    Premises #1 Instructions: Add / New Delete
       Street Address:
       Suite Number:         City:
       State:         Zip Code:

2.    Premises #2 Instructions: Add / New Delete
       Street Address:
       Suite Number:         City:
       State:         Zip Code:

       Click here to skip ahead if you are deleting locations only
       If you are reporting new premises, complete the following questions for each:

3.    New Premises # (use number from above)
       Interest: Rent / Lease Own Net Lease (i.e. you must insure building)
       Approx. Age of Building:          Number of Stories:
       Square Footage You Occupy:         % of Building: %
       Building Construction Type: Wood Frame Joisted Masonry (wood only in roof or joists) Masonry (including roof and joists) Certified Fire Resistive
       Other Neighboring Businesses -- What Types of Companies?
    `  

       Fire Protection: (select all that apply)        Theft Protection: (select all that apply)
       Fire Extinguisher Sprinkler System Central Station Alarm Alarm that rings at premises only Open 24 Hours          Dead Bolts Guard Service Central Station Alarm Alarm that rings at premises only Open 24 Hours

       Click here to skip ahead if you are adding no other locations
       If you are reporting a second new premises, complete the following questions:

4.    New Premises # (use number from above)
       Interest: Rent / Lease Own Net Lease (i.e. you must insure building)
       Approx. Age of Building:          Number of Stories:
       Square Footage You Occupy:         % of Building: %
       Building Construction Type: Wood Frame Joisted Masonry (wood only in roof or joists) Masonry (including roof and joists) Certified Fire Resistive
       Other Neighboring Businesses -- What Types of Companies?
       

       Fire Protection: (select all that apply)        Theft Protection: (select all that apply)
       Fire Extinguisher Sprinkler System Central Station Alarm Alarm that rings at premises only Open 24 Hours          Dead Bolts Guard Service Central Station Alarm Alarm that rings at premises only Open 24 Hours

5.    Add Landlord(s) as Additional Insured?   YES  NO
        Premises # (use number from above)
        Landlord Name:
        Street Address:
        Suite Number:         City:
        State:         Zip Code:
        Issue Certificate of Insurance to Landlord?   YES  NO

        Premises # (use number from above)
        Landlord Name:
        Street Address:
        Suite Number:         City:
        State:         Zip Code:
        Issue Certificate of Insurance to Landlord?   YES  NO

6.    Address/Location Change: Additional Instructions or Comments?   
            

       Finished - Ready to Submit             Select Another Type of Change

Office Property Values:

1.    Location of Change (address):

2.    Computer Equipment: Change Value Add Category Delete Category
        New Value (if any): $

3.    Radio/Telecom. Equipment: Change Value Add Category Delete Category
        New Value (if any): $

4.    Other Personal Business Property: Change Value Add Category Delete Category
        New Value (if any): $

5.    Building (structure): Change Value Add Category Delete Category
        New Value (if any): $

6.    Improvements & Betterments: Change Value Add Category Delete Category
        New Value (if any): $

7.    Business Income / Extra Expense: Change Value Add Category Delete Category
        New Value (if any): $

8.    Other Property Category: Change Value Add Category Delete Category
        Describe Property:
        New Value (if any): $

9.    Unless you specify otherwise, terms like deductibles, coinsurance,
       and valuation will reflect those for existing coverage.   
           

10.   Add Lessor as Loss Payee?   YES  NO
        Describe Property:
        Value of Property: $
        Lessor Name:
       Street Address:
        Suite Number:         City:
        State:         Zip Code:
        Issue Evidence of Insurance to Lessor?   YES  NO

       Finished - Ready to Submit             Select Another Type of Change

Auto - Vehicle Change:  you may add/delete up to two vehicles

1.  Vehicle #1 Instructions:  Add / New Delete

      Year:        Make:        
      Model:

      Vehicle ID No. (VIN):    
      GVW: (if over 10,000 lbs)

      Type: Private Passenger Car Minivan Pickup Sport Utility Vehicle Medium Truck (under 20,000 lbs GVW) Heavy Truck Tractor Trailor       Cost New: $

      Use:  Delivery to businesses Delivery to private homes Spare Delivery Vehicle Executive Vehicle Sales Vehicle          Normal Radius of Use: Under 50 miles 51-100 miles 101-250 miles Over 250 miles

      Do You Wish to Cover Damage to the Vehicle?   YES  NO
      If yes, indicate Preferred Deductible: $ (normally $1000 for trucks, $500 other)

      Unless you specify otherwise, liability, UM, PIP coverages and limits will match
       those of other similar vehicles already on your policy.  Special instructions?
   
           
        

2.  Vehicle #2 Instructions:  Add / New Delete

      Year:        Make:        
      Model:

      Vehicle ID No. (VIN):     
      GVW: (if over 10,000 lbs)

      Type: Private Passenger Car Minivan Pickup Sport Utility Vehicle Medium Truck (under 20,000 lbs GVW) Heavy Truck Tractor Trailor       Cost New: $

      Use:  Delivery to businesses Delivery to private homes Spare Delivery Vehicle Executive Vehicle Sales Vehicle          Normal Radius of Use: Under 50 miles 51-100 miles 101-250 miles Over 250 miles

      Do You Wish to Cover Damage to the Vehicle?   YES  NO          
      If yes, indicate Preferred Deductible: $  (normally $1000 for trucks, $500 other)

      Unless you specify otherwise, liability, UM, PIP coverages and limits will match
      those of other similar vehicles already on your policy.  Special instructions?
   
           

       Note:  KBS can run Motor Vehicle Reports on new drivers or help you enroll to order MVRs
                 yourself on-line.  See our on-line form under "Client Services" or call us today!

       Finished - Ready to Submit             Select Another Type of Change

Other Change Request:

1.    Describe Type of Change:

2.    Additional Comments (if any):
      

       Finished - Ready to Submit             Select Another Type of Change

Thank you for keeping your insurance updated.  KBS will do our part to make
sure your request is processed accurately and efficiently by your carrier. 

>    Please follow any instructions for sending documentation to KBS
>    Please watch for a confirming e-mail.  *Requests are not valid unless confirmed*
>    To contact KBS, call 1-888-KBS-4321  (8:30 AM - 6:00 PM EST)
>    To fax KBS: 914-636-0802
>    Complete a Client Service Survey -- receive a FREE gift!

        Review Form -- Back To Top