Change Request - Building - Hickok & Boardman Insurance Group

Your Name

First Last

Your Phone

City Department

Your email address*

Enter Email Confirm Email

Are you adding or removing a building?

Building Information

Effective Date

Construction Type

Property Address

Street Address Address Line 2 City State ZIP Code

Year of Construction

Fire Protection

Number of Stories

Burglar / Theft Protections

Sq, Footage of Building

Value of Building

Value of Business Personal Property at this location?

Building Use

Other Occupancies of Building

Is there a loan on this property?

Mortgagee Name

First Last

Mortgagee Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Property Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

Project Number, if applicable