Policy Change Request Please complete the form below for a policy change request. Use this form to make a request to have your policy changed. Type of Change* Commercial Policy Personal Policy Name on Policy*Policy Type (Describe)*Effective Date Requested*Description of Policy Change*Your Full Name*Email Address*Your Phone Number*Disclaimer* By checking this box I understand that insurance coverage cannot be changed, altered or bound until I receive direct confirmation by a licensed agent representing Mid America Specialty Markets
