Request to Add/Delete a Loss Payee

Please note that this form is for a REQUEST ONLY. By submitting this form it does not bind coverage in any way. If you do not hear from us in a reasonable amount of time, ASSUME WE DID NOT GET THIS REQUEST FOR AN INSURANCE QUOTE, and call our office.

I understand that filling out and submitting this form DOES NOT bind coverage in any way, and the only way coverage can be bound will be when I am informed of a binder or policy is issued by the agent representing me. Please note that coverage cannot be bound or changed by using the Internet or Email.

Insured's Name

Email Address
Policy Number
Effective Date of Change
Add / Delete?
Certificate Holder
 Additional Insured
 Loss Payee

Loss Payee's Name, Address & Loan Number, if Required

Street or P.O. Box
Loan Number (if applicable)
If adding a loss payee, indicate if for business personal property or equipment
 Business Personal Property

If equipment, describe indicating serial numbers and value to insure

Serial #

Additional Information

In the box below, please provide any additional information you feel may be necessary for this Loss Notice form.

Requested By
Email Address

Before submitting this form, please click on the link below to move the contents of box "A" into box "B" leaving the first box empty.

A: B: Click to Move


Gifford-Heiden Personal InsuranceGifford-Heiden Personal InsuranceGifford-Heiden Personal Insurance
Gifford-Heiden Insurance

Gifford-Heiden Insurance Agency
111 East Venice Avenue
Venice, Florida 34285
Phone: (941) 484-0681
Phone:(941) 366-0500
Fax: (941) 485-3835
Office Hours: Mon-Fri 8:30am-5:00pm

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