Hallmark Equine Insurance Agency

Request A Policy Change

Need to request a simple change to your policy?
Moved or changed your name?
Need to notify Hallmark that you sold a horse?

You can use the form below to request a change to your policy.

Please note:

No changes will be made until underwriting accepts the request and issues an endorsement to your policy.

Your Contact Information

	*	Required field.
Name:	*
Address:	*
City:	*
State:	*
Zip:	*
Policy Number (if available):
Tel:	*	(ex:8478448419)
Fax:
Email:	*
		We will respond to you by e-mail. If you need an immediate assistance during business hours, please call us at (800) 734-0598.
How would you like us to respond to you if we have questions?	*

General Policy Change Request

Change your name

Current name:
New name:

Change your address

Current address:
New address:

Change your telephone

Current telephone:
New telephone:

Change your Email

Current Email:
New Email:

Mortality Change Request

Change a horse name. (Please provide the name as it currently appears on the policy, along with new name.)

Current horse name:
New name for horse:

Change a horse's use. (Please provide the name as it currently appears on the policy, along with new use. Please note, use changes may result in a premium change.)

Current horse name:
New use for horse:

Notification of the sale of a horse. (Please make sure you provide us with the horse's name as it appears on the policy and the date of sale. Please provide a copy of the bill of sale if available.)

Horse name:
Date of sale:	(ex: mm/dd/yyyy)

Other requests. (Please enter other change requests here, including the desired effective date of the change.)

Liability/Property Change Request

Request an Additional Insured be added to your policy.

Name of Additional Insured:

Address of Additional Insured:

Please provide the relationship of the requested Additional Insured to you. For example, land owner, or owners of facilities you operate at. Please include the Event Name and Date if applicable.

Request a Certificate of Insurance.

Do you need an Additional Insured Listed? If so, Name of Additional Insured:

Address of Additional Insured:

Please provide information on where Certificate should be sent.

Comments / Special Instructions:

Request addition of a Public Event Date.

Public event date(s):

Description of event:

Sanctioning Organization(s):

Location of event:

Description of event activities:

Average number of participants per Show / Event:

Average number of spectators per Show / Event day:

Maximum number of participants:

Maximum number of spectators:

Request cancellation of a Public Event Date.
(If you need to reschedule a date, please add the new date above and list the cancelled date(s) below.)

Cancelled Public event date(s):

Reason for cancellation:


Note: Cancelled or Rescheduling Public Event Days.

If your club or association cancels a Public Event Day, you must submit written notice of the cancellation along with the reason within 7 days of the cancelled event in order to permit the rescheduling of this day without an additional premium.

Other requests.
(Please enter other change requests here, including the desired effective date of the change.)

Verification

What is the answer to this math question 10 + 8

Hallmark Equine Insurance Agency, Inc.
2175 Point Boulevard � Suite 185 � Elgin, IL 60123
(800) 734-0598 • (847) 844-8419 • Fax: (847) 844-8284
E-mail: info@hallmarkhorse.com