\r\n Policyholder Name Change\r\n
\r\n\r\n Instructions for submitting this form to the American Modern\r\n Insurance Group:\r\n
\r\n\r\n Clicking on the Submit button on the last page of this form will\r\n electronically send your information to the American Modern\r\n Insurance Group.\r\n
\r\n\r\n This form allows you to make a change to your name noted on your\r\n policy. If you need help with this form please contact Customer\r\n Care at 1-800-543-2644.\r\n
\r\n\r\n Policyholder Mailing Address Change\r\n
\r\n\r\n Instructions for submitting this form to the American Modern\r\n Insurance Group:\r\n
\r\n\r\n Clicking on the Submit button on the last page of this form will\r\n electronically send your information to the American Modern\r\n Insurance Group.\r\n
\r\n\r\n This form allows you to make a change to your mailing address\r\n noted on your policy. If you need help with this form please\r\n contact Customer Care at 1-800-543-2644.\r\n
\r\n\r\n Policy Documents Request\r\n
\r\n\r\n Instructions for submitting this form to the American Modern\r\n Insurance Group:\r\n
\r\n\r\n Clicking on the Submit button on the last page of this form will\r\n electronically send your information to the American Modern\r\n Insurance Group. However, you also have the option of printing\r\n the form and faxing or mailing the page(s) to us.\r\n
\r\n\r\n This form allows you to make a request for policy documents. If\r\n you need help with this form please contact Customer Care at\r\n 1-800-543-2644.\r\n
\r\n\r\n Agency ACORD AL3 Request\r\n
\r\n\r\n Instructions for submitting this form to the American Modern\r\n Insurance Group:\r\n
\r\n\r\n This agency policy download request form is for ACORD AL3\r\n Compliant Agency Management Systems{\" \"}\r\n
\r\n\r\n Once we have received this completed form, and have verified\r\n your agency codes and IVANS information, it will take five\r\n business days for us to add your agency to our IVANS batch\r\n files. If you have questions or need assistance, contact us:{\" \"}\r\n \r\n systemsupport@amig.com\r\n {\" \"}\r\n or 866-527-9583\r\n
\r\n\r\n To set up your account, tell us about your agency.\r\n
\r\n\r\n If you broker your business through a GA, enter that name and\r\n code. If you work for the GA, please enter your agency\r\n information.\r\n
\r\n\r\n Who in your agency manages the policy download process?\r\n
\r\n\r\n What software package do you use?\r\n
\r\n\r\n Policy information is sent to your agency system via IVANS.\r\n Please enter the following information about your IVANS\r\n account.\r\n
\r\n\r\n We can add commission information for those products that are\r\n part of the policy download. You must enter all of the codes\r\n used by your agency. If you receive your commission from a GA,\r\n no data will be transmitted.\r\n
\r\n\r\n By checking this box, I represent that I am authorized\r\n to act on behalf of the agency identified above and\r\n consent to the electronic delivery of the following\r\n agency downloads, as available and applicable to my\r\n agency: (Please check all that apply)\r\n
\r\n \r\nPolicy Downloads
\r\n \r\n\r\n Commission Reporting\r\n
\r\n \r\n\r\n Agent User Linking Request\r\n
\r\n