Complete and mail or fax to:

Alliant Insurance Services, Inc.4530 Walney Road, Suite 200

Chantilly, VA 20151(800) 298-7373 / (703) 397-0995 Fax

E-mail: conserve@alliantinsurance.com

1

Policy Change, Addition, or Deletion Contact Information

Named insured: Effective date of change:

Mailing address:

City: State: ZIP Code:

Contact name: Email:

Phone: Fax:

Delete Location To delete coverage, list location(s) (include address, square feet applicable, and/or number of acres)

Add Location To add new coverage for contents or a building:

1) List new owned, leased, managed, or easement acres below and 2) Complete “Location Questionnaire” (page 2 of this form)

PROPERTY NAME STREET ADDRESS OR APN COUNTY, STATE, ZIP CODE NUMBER OF ACRES

Revised new total owned: Revised new total easement:

Reminder

An office set up for the organization in a private home must be included on the policy. Although the building is not being insured since it is not owned by the organization, the contents owned and square feet occupied by the organization are being insured.

2 Rev. 6/09

Location Questionnaire

Contact Information Check here if contact information is same as page 1

Named insured: Effective date of change:

Mailing address:

City: State: ZIP Code:

Contact name: Email:

Phone: Fax:

New Location

Address:

City: State: ZIP Code:

Location Details

Primary use of space: Office Residence Storage Garage Nature center Trail

Building condition: Poor Good Excellent

Building construction: Masonry/brick Frame Year built:

Does your organization own the building? Yes No

If owned, name and address of mortgagee if financed:

Acres owned: Acres under easement:

Replacement cost of building: $ Replacement cost of contents: $

Replacement cost of computer equipment: $

Total square feet occupied: Number of stories:

Is building currently occupied with contents? Yes No

If no, approximate date it will be occupied:

Is building attached to another building? Yes No

Heating system: Electric Oil

Sprinkler system: Yes No

Alarm system: Yes No

If yes, type of system:

For buildings more than 25 years old, have electrical and plumbing systems been upgraded? Yes No

If yes, provide date and details of upgrade:

Other occupants in building: Offices Warehouse Retail Other: Distance from public fire hydrant: Distance from fire department:

Completed By

Name: Date: