Dance Insurance - K&K Insurance Brokers, Inc Canada.

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Dance Insurance


Phone	PhoneNumber 1-800-753-2632
Fax	FaxNumber 1-905-602-9141
Claims	ClaimsNumber kk_canada@kandkcanada.com

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Policy Change Request Form

* fields are mandatory

Current Information

*Named insured (as it appears on your certificate of insurance):

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*Policy number (as it appears on your certificate of insurance):

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*

Contact first name:

*

Contact last name:

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Effective date of change(s):

Please enter the correct date format (mm/dd/yyyy). That date entered must be today’s date or later.

*

Phone:

Cell:

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*

E-Mail:

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Please indicate the type of change needed and complete the appropriate section

Cancel coverage	Limit of coverage	Cancel/change event date
Mailing address	Certificate amendments and/or requests	Named insured
Contact name	Phone, fax and/or e-mail	Facility location
Type of operation	Other (please explain) Invalid Characters
Please select		Please enter field

Note: Some changes may result in an increase of premium due and will be effective the day after receipt or a later date.

Cancel Coverage

*Effective date of cancellation:	Please enter field

*Reason for cancellation: (Refund Policy)

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Note: Coverage cannot be cancelled prior to K&K's receipt of this form.

Change Limit of Coverage (an increase in liability limits will result in additional premium due)

*Type of coverage:

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*Current liability limit:		*New limit requested:
	Invalid Characters Please enter field		Please enter field Invalid Characters

Cancel/Change Event Date

*Effective date of cancellation/change:
	Please enter field
*Reason for cancellation/change: (Refund Policy)	Please enter field Invalid Characters
Note: Request must be received by K&K prior to day of event.

Named Insured, Contact Name, Mailing Address, Fax or E-mail Change Information
Only enter the fields to be changed.

*Named insured:	Please enter field Invalid Characters
*Mailing address:	Please enter field Invalid Characters
	Invalid Characters
*City:	Please enter field Invalid Characters
*Province:	Please select
*Postal Code:	Please enter field

*Contact first name:	Invalid Characters	*Contact last name:	Invalid Characters
	Please enter field		Please enter field

E-mail:		Cell:
	Please enter field Invalid email ID entered.		Please enter field
Phone number:		Fax:
			Please enter field

Request Certificate

*Type of request: Please select

Change/amendment request to a certificate already issued
New certificate request

Certificate of insurance request

*This certificate is for our: Please select

Program coverage (commercial general liability) Equipments & contents coverage

*Check the type of certificate you are requesting: (what's this?)

Please select

Additional insured	Evidence of coverage	Loss payee (Inland Marine/Equipments & Contents)

Certificate holder information

*

Entity name (as it should appear in the certificate):

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*

Mailing address:

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*

City:

Please enter field

*

Province:

Please select

*

Postal Code:

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*Relationship to insured entity:

Please select

Owner/lessor of premises	Sponsor	Co-promoter	Mortgagee	Franchisor
Event Organizer	Lessor of Equipments and Contents
Other (please identify/explain)	Invalid Characters
Please enter field

If applicable

Dates of events/activity:

From

To

Please enter the correct date format (mm/dd/yyyy).

Please enter the correct date format (mm/dd/yyyy).

Hours of events/activity:

From

AM

PM

To

AM

PM

Types of events/activity:

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Name of events/activity:

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Location of events/activity:

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Need by date:

Please enter the correct date format (mm/dd/yyyy).

Special certificate language needed (please explain):

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Add Another Certificate

Information

Do you want to delete the record?

Facility Location Change

*Select:

Replacement facility location	Additional facility location	Delete facility location
Please select

*Mailing address:

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*City:

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*Province:

Please select

*Postal Code:

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*New facility square footage:

sq. ft. The information you entered is invalid, please try again. Please enter field

*Was there a change in the insured's annual sales?	Yes No Please select
*Provide the new annual sales:	$ Please enter field Invalid Information
*Is there a change in total number of members?	Yes No Please select
*Provide new total number of members:	Please enter field Invalid Information

Type of Operation

*Please provide the type of change:

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Other

*Please explain/describe change:

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Document Delivery

This certificate will be delivered based on the option you indicate below. Please select

		E-mail to:		Attn:	Invalid Characters
			Invalid email ID entered. Please enter field
		Fax to:		Attn:	Invalid Characters
			Please enter field
		Mail to:		Attn:	Invalid Characters
		Mailing address:	Invalid Characters Please enter field
			Invalid Characters
		City:	Invalid Characters Please enter field
		Province:	Please select
		Postal Code:	Please enter field

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