Server: Microsoft-IIS/3.0 Date: Thu, 18 Dec 1997 10:55:15 GMT Content-Type: text/html Accept-Ranges: bytes Last-Modified: Thu, 30 Oct 1997 21:10:07 GMT Content-Length: 17047 Request for Literature

Request for Literature

To receive literature by mail please follow these 3 steps:


Policyholder Name:
Policy Number: AP
Residence Phone: ( ) -
Business Phone: ( ) -   Extension:

 


 

Duplicate Declaration - A copy of your current policy.

 

Contract - A copy of the current contract between 20th Century Industries and our policy holders.

 

Full Comparison Quotation - A quotation showing all the coverages available based on your current policy information, including your current autos and drivers.

 

Statement of Account - This is a detailed listing of your policy billing information.

 

Canada Card - This is an endorsement used as proof of insurance while traveling in Canada. Your policy must be paid through the dates of your trip. Please complete the following information to request the endorsement.
 
Year and Make of auto you will be driving:

( If you are planning on renting an auto for the entire time you will be in Canada, please type "rental auto" )

When will you be in Canada?
From / /
to / /

 

An endorsement to delete Uninsured Motorist Bodily Injury coverage - This endorsement allows you to remove the Uninsured Motorist Bodily Injury coverage from your policy. The endorsement must be signed, dated and returned before we will delete the Uninsured Motorist Bodily Injury coverage from your policy.
 

 

An endorsement to reduce Uninsured Motorist Bodily Injury coverage - This endorsement allows you to select Uninsured Motorist Bodily Injury coverage limits that are less than your Bodily Injury Liability coverage. The endorsement must be signed, dated and returned before we will lower your Uninsured Motorist Bodily Injury coverage below your current Bodily Injury Liability coverage limits.

Please select the limits you would like for Uninsured Motorist Bodily Injury coverage:

15 / 30     25 / 50
 

 

An endorsement to exclude a driver - This endorsement allows you to remove the coverage from and the rates charged for a specific driver. The endorsement must be signed, dated and returned before we will exclude the driver from your policy. Please complete the following information to request the endorsement.

Driver to be excluded:
First Name
Middle Initial
Last Name
Driver's License Number
Date of Birth ( Month / Day / Year ) / /

Reason for the exclusion :

( If the driver is living away from home in order to attend school, please list the name, city, and zip code of the school )

 

If you have recently moved, please check here.
(Be sure to complete a change of address if you have not already done so).