Palmer & AssociatesPalmer & Associates
78 Eastern Blvd
PO Box 536
Glastonbury, Connecticut 06033
Phone: (860) 633-3567
Toll Free: (888) RPALMER

Personal Insurance Policy Change Request (other than auto/home)

Binding Agreement

(Required) I understand that any policy changes and quote requests are effective only when I have received a written confirmation.*

I agree

Requestor Information

First Name (on policy)*

Last Name (on policy)*

Policy Number:

Email Address:*

Phone Number:*

Policy Change Request

Type of Policy:*

Description of Change Requested:*

Effective Date Change is Desired:*

Other Coverage and Risk Considerations

Some policy changes can create gaps in coverage or other risks. Some common coverage limitations are listed below. Would you like us to contact you to review aspects of your insurance program with you?*

Yes No

Please check any areas where you feel there may be a protection gap:

Questions or Comments

*Required fields:

This submission is a request. Insurance coverage changes and new coverages are not effective until we confirm that for you.

We will do our best to complete this request based on the information you provide. The more complete your information, the more accurate your quote will be.

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