Contact Change / Update Form

Organization / Insured Information

Named Insured*

As it appears on the policy.

City, State*

Where is Named Insured located?

Sport/Organization Type/Affiliation*

(Ex: Baseball, Football, Dixie, Dizzy, SODA, AYF, Amateur, Facility, Studio, etc.)

Effective Date of Policy

Effective Date of Change (if future date)

Please indicate which of the options below is correct regarding the insurance administrator of your organization.*

I am still the contact, however, I need to update my contact information.
I am still the contact, however, I would like to add an additional contact to the account.
I am the new contact and would like to provide updated contact information.
I am no longer the contact, however, I can provide you with the new contact's information.

Reason for Change (If changing contact entirely)*

Previous contact is no longer affiliated with the organization.
Previous contact is still affiliated with the organization, but no longer handling the insurance.

If any updates are to be made, please indicate below.
Please provide as much information as possible, if known.

New Contact Person's Name (If applicable)

First

Last

Email

Phone

Address

Street Address

Address Line 2

City

State / Province / Region

ZIP / Postal Code

Country

Authorized Party*

First

Last

Relationship to Named Insured*

Authorized Party - Email*