www.contacthiscox.com
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64.253.38.183
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Submitted URL: http://www.contacthiscox.com/partner/
Effective URL: https://www.contacthiscox.com/partner/
Submission: On April 15 via manual from US — Scanned from GB
Effective URL: https://www.contacthiscox.com/partner/
Submission: On April 15 via manual from US — Scanned from GB
Form analysis 1 forms found in the DOM
POST ./
<form method="post" action="./" id="Form1" enctype="multipart/form-data">
<div class="aspNetHidden">
<input type="hidden" name="__VIEWSTATE" id="__VIEWSTATE" value="/wEPDwULLTE4NzA0MjI4MzEPZBYCZg9kFgICAQ8WAh4HZW5jdHlwZQUTbXVsdGlwYXJ0L2Zvcm0tZGF0YRYCAgEPZBYCAgEPFgIeBXN0eWxlBQ1kaXNwbGF5Om5vbmU7ZGSKkJmJ4TUSK4aY/omPOWUpOyJCMrFMJgRgyWrv0cj0rQ==">
</div>
<script type="text/javascript" src="/partner/ajaxpro/prototype.ashx"></script>
<script type="text/javascript" src="/partner/ajaxpro/core.ashx"></script>
<script type="text/javascript" src="/partner/ajaxpro/converter.ashx"></script>
<script type="text/javascript" src="/partner/ajaxpro/ASP.default_aspx,App_Web_ijgcdsd4.ashx"></script>
<div class="aspNetHidden">
<input type="hidden" name="__VIEWSTATEGENERATOR" id="__VIEWSTATEGENERATOR" value="8E118862">
<input type="hidden" name="__EVENTVALIDATION" id="__EVENTVALIDATION" value="/wEdAAQQbCo/fO014iD0qMMudJ/RgGqaIon0gLZzQejBnP4qRUw0/uFolMAN4Tyy+UIBSv8LMpCvcyKxCPFQ1roEN3bwPtFX+WYjCox+0m9NWI4gfA49BrdgV1r4X/uz+EboXGg=">
</div>
<div class="main-container">
<div class="header">
<div class="logo-home">
<img border="0" title="Hiscox: Encourage courage" alt="Hiscox: Encourage courage" src="/Styles/img/Hiscox_Encourage_courage.png" id="hiscox_logoEncc">
</div>
<div class="header-title"> Policy Management<br>1-866-739-0727 </div>
</div>
<!-- a href="Reports.aspx" class="no-print">report...</a -->
<div class="clear">
</div>
<div class="page-container">
<script type="text/javascript" src="/Scripts/orangebox.min.js"></script>
<script type="text/javascript">
oB.settings.addThis = false;
</script>
<link rel="stylesheet" type="text/css" href="/Styles/orangebox.css">
<input type="hidden" name="ctl00$MainContent$fstep" id="MainContent_fstep" value="1">
<script type="text/javascript">
$(function() {
//Add checkbox handlers
$(':checkbox').change(function() {
updateRadios();
});
//updateRadios
updateRadios();
});
function checkFile(control) {
var f = control.files[0]
var ext = f.name.match(/\.([^\.]+)$/)[1];
ext = ext.toLowerCase();
var allow = ASP.default_aspx.checkUploadedSize(f.size);
if (ext != "pdf" && ext != "jpg" && ext != "jpeg" && ext != "msg" && ext != "html" && ext != "doc" && ext != "docx" && ext != "xls" && ext != "xlsx") {
$(MainContent_lblUploadError).text("File extension not allowed. Only pdf, jpg, jpeg, msg, html, word and excel files are allowed.");
$(MainContent_btnUpload).hide();
//ASP.default_aspx.disableUpload();
//alert("File extension not allowed. Only pdf, jpg and jpeg are allowed.")
} else if (f.size > 26214400 || f.fileSize > 26214400) {
//show an alert to the user
$(MainContent_lblUploadError).text("Allowed file size exceeded. (Max. 25 MB)");
$(MainContent_btnUpload).hide();
//ASP.default_aspx.disableUpload();
//alert("Allowed file size exceeded. (Max. 20 MB)")
//reset file upload control
this.value = null;
} else if (!allow.value) {
$(MainContent_lblUploadError).text("Limit for total size of files exceeded. (Max. 25 MB)");
$(MainContent_btnUpload).hide();
} else {
$(MainContent_lblUploadError).text("");
$(MainContent_btnUpload).show();
}
}
function updateRadios() {
var chkCount = 0;
if ($('#qId_467').is(':checked')) chkCount += 1;
if ($('#qId_468').is(':checked')) chkCount += 1;
if ($('#qId_469').is(':checked')) chkCount += 1;
if (chkCount > 1) {
$('#l_488').text("Landlord (only applicable to GL and BOP)");
$('#l_489').text("Loss payee (only applicable to BOP)");
} else {
$('#l_488').text("Landlord");
$('#l_489').text("Loss payee");
}
if (($('#qId_648').is(':checked') && $('#qId_648').is(":visible")) || ($('#qId_561').is(':checked') && $('#qId_561').is(":visible")) || ($('#qId_711').is(':checked') && $('#qId_711').is(":visible")) || ($('#qId_712').is(':checked') && $(
'#qId_712').is(":visible"))) {
$('#MainContent_sctnUpload').show();
} else {
$('#MainContent_sctnUpload').hide();
}
}
$(function() {
return;
$('.question').mouseover(function(event) {
createTooltip(event);
}).mouseout(function() {
// create a hidefunction on the callback if you want
//hideTooltip();
});
});
function createTooltip(event) {
var d = '<div class="qtooltip">';
d += $(event.target).text();
d += '</div>';
if ($('.qtooltip')[0]) {
$('.qtooltip').text($(event.target).text());
} else $(d).appendTo('body');
positionTooltip(event);
};
function positionTooltip(event) {
var tPosX = event.target.offsetLeft + 30;
var tPosY = event.target.offsetTop + 20;
$('div.qtooltip').css({
'position': 'absolute',
'top': tPosY,
'left': tPosX
});
};
</script>
<div class="cnt-sctn no-bg">
<div id="MainContent_error_id" class="error-summary" style="display:none;">
<div class="error-text">
<span class="no-print">The highlighted questions contain errors. Please review and amend.</span>
</div>
</div>
<span id="MainContent_mainContainer">
<div id="MainContent_sctn11" class="SectionContainer">
<div class="cnt-subsctn">
<div class="top">
<div class="right">
<div class="left">
<div class="middle"></div>
</div>
</div>
</div>
<div class="middle-content">
<div class="page-heading2">
<h1 class="page-heading-h1">
</h1>
</div>
<div class="clear"></div>
</div>
<div class="bottom clear-both">
<div class="right">
<div class="left">
<div class="middle"></div>
</div>
</div>
</div>
</div>
<div class="_form">
<div id="MainContent_qr_465" class="questionBlock" style="display:block;">
<span class="questionTitle">This site allows you to quickly request servicing on your client’s policy or submit a general inquiry. Most requests will be responded to within 1 business day.<br><br> If you have any questions or need to
speak with us regarding your request, please contact us at 1-866-739-0727, Mon – Fri from 7 am to 10 pm ET.<br></span>
</div>
</div>
</div>
<div id="MainContent_sctn1" class="SectionContainer">
<div class="cnt-subsctn">
<div class="top">
<div class="right">
<div class="left">
<div class="middle"></div>
</div>
</div>
</div>
<div class="middle-content">
<div class="page-heading2">
<h1 class="page-heading-h1">Your Information </h1>
</div>
<div class="clear"></div>
</div>
<div class="bottom clear-both">
<div class="right">
<div class="left">
<div class="middle"></div>
</div>
</div>
</div>
</div>
<div class="_form">
<div id="MainContent_qr_631" class="questionBlock" style="display:none;">
<div class="question qt_text">First Name*<br></div>
<div class="answer at_textbox"><input id="qId_631" name="qId_631" type="text" value="" maxlength="500" onchange="echoStub(this);" onkeypress="return noenter(event)"></div>
</div>
<div id="MainContent_qr_632" class="questionBlock" style="display:none;">
<div class="question qt_text">Last Name*<br></div>
<div class="answer at_textbox"><input id="qId_632" name="qId_632" type="text" value="" maxlength="500" onchange="echoStub(this);" onkeypress="return noenter(event)"></div>
</div>
<div id="MainContent_qr_701" class="questionBlock" style="display:block;">
<div class="question qt_text">Hiscox Partner/Wholesaler Affiliation<br></div>
<div class="answer at_"><input id="qId_701" name="qId_701" type="text" value="" maxlength="500" onchange="echoStub(this);" onkeypress="return noenter(event)"></div>
</div>
<div id="MainContent_qr_419" class="questionBlock" style="display:block;">
<div class="question qt_text">Name<br></div>
<div class="answer at_"><input id="qId_419" name="qId_419" type="text" value="" maxlength="500" onchange="echoStub(this);" onkeypress="return noenter(event)"></div>
</div>
<div id="MainContent_qr_700" class=" hidden hidden questionBlock" style="display:block;">
<div class="question qt_text">Agent ID<br></div>
<div class="answer at_"><input id="qId_700" name="qId_700" type="text" value="" maxlength="500" onchange="echoStub(this);" onkeypress="return noenter(event)"></div>
</div>
<div id="MainContent_qr_509" class="questionBlock" style="display:block;">
<div class="question qt_text">Email Address<br></div>
<div class="answer at_"><input id="qId_509" name="qId_509" type="text" value="" maxlength="500" onchange="echoStub(this);" onkeypress="return noenter(event)"></div>
</div>
<div id="MainContent_qr_508" class="questionBlock" style="display:block;">
<div class="question qt_text">Phone Number<br></div>
<div class="answer at_"><input id="qId_508" name="qId_508" type="text" value="" maxlength="500" onchange="echoStub(this);" onkeypress="return noenter(event)"></div>
</div>
<div id="MainContent_qr_560" class=" hidden hidden questionBlock" style="display:block;">
<div class="answer at_checkbox"><input id="qId_560" name="qId_560" autocomplete="off" type="checkbox" onclick="validateAnswers(this);" value="True"></div>
<div class="question qt_checkbox">Policy Servicing Requests<br></div>
</div>
<div id="MainContent_qr_703" class=" hidden hidden questionBlock" style="display:block;">
<div class="answer at_checkbox"><input id="qId_703" name="qId_703" autocomplete="off" type="checkbox" onclick="validateAnswers(this);" value="True"></div>
<div class="question qt_checkbox">Agent & Partner Servicing Requests<br></div>
</div>
<div id="MainContent_qr_562" class=" hidden hidden questionBlock" style="display:none;">
<div class="endCheckList"></div>
<div class="question qt_text">Your Hiscox partner/wholesaler affiliation<br></div>
<div class="answer at_textbox"><input id="qId_562" name="qId_562" type="text" value="" maxlength="500" onchange="echoStub(this);" onkeypress="return noenter(event)"></div>
</div>
<div id="MainContent_qr_462" class=" hidden hidden questionBlock" style="display:block;">
<div class="question qt_text">Email address<br></div>
<div class="answer at_"><input id="qId_462" name="qId_462" type="text" value="" maxlength="500" onchange="echoStub(this);" onkeypress="return noenter(event)"></div>
</div>
<div id="MainContent_qr_463" class=" hidden hidden questionBlock" style="display:block;">
<div class="question qt_text">Phone number<br></div>
<div class="answer at_"><input id="qId_463" name="qId_463" type="text" value="" maxlength="500" onchange="echoStub(this);" onkeypress="return noenter(event)"></div>
</div>
<div id="MainContent_qr_660" class=" hidden hidden questionBlock" style="display:none;">
<div class="question qt_textzone">Please provide any special wording required on the certificate.<br></div>
<div class="answer at_textzone"><textarea id="qId_660" name="qId_660" maxlength="1000" onchange="echoStub(this);"></textarea></div>
</div>
</div>
</div>
<div id="MainContent_sctn17" class="SectionContainer">
<div class="cnt-subsctn">
<div class="top">
<div class="right">
<div class="left">
<div class="middle"></div>
</div>
</div>
</div>
<div class="middle-content">
<div class="page-heading2">
<h1 class="page-heading-h1">Policy Servicing Requests </h1>
</div>
<div class="clear"></div>
</div>
<div class="bottom clear-both">
<div class="right">
<div class="left">
<div class="middle"></div>
</div>
</div>
</div>
</div>
<div class="_form">
<div id="MainContent_qr_460" class="questionBlock" style="display:block;">
<div class="question qt_text">Named insured (Business name)<br></div>
<div class="answer at_"><input id="qId_460" name="qId_460" type="text" value="" maxlength="500" onchange="echoStub(this);" onkeypress="return noenter(event)"></div>
</div>
<div id="MainContent_qr_461" class="questionBlock" style="display:block;">
<div class="question qt_text">Hiscox policy number<br></div>
<div class="answer at_"><input id="qId_461" name="qId_461" type="text" value="" maxlength="500" onchange="echoStub(this);" onkeypress="return noenter(event)">
<div class="help" style="float: right;">
<span class="hlpinit"><img src="/Styles/img/info.png" alt="i" onclick="$('hlpDisp').toggle();"></span>
<div class="hlpDisp"> You can find the policy number on the upper right hand corner of the policy documents or emails we've sent you. <br>The policy number will follow one of these formats: <br>UDC-1234567-CGL-99
<br>UDC-1234567-EO-99 <br>UDC-1234567-BOP-99 </div>
</div>
</div>
</div>
<div id="MainContent_qr_464" class="questionBlock" style="display:block;">
<span class="questionTitle">Please select one or more of the following options<br></span>
</div>
<div id="MainContent_qr_491" class="questionBlock" style="display:block;">
<div class="answer at_checkbox"><input id="qId_491" name="qId_491" autocomplete="off" type="checkbox" onclick="validateAnswers(this);" value="True"></div>
<div class="question qt_checkbox">Issue an Additional Insured an ACORD certificate<br></div>
</div>
<div id="MainContent_qr_492" class="questionBlock" style="display:block;">
<div class="answer at_checkbox"><input id="qId_492" name="qId_492" autocomplete="off" type="checkbox" onclick="validateAnswers(this);" value="True"></div>
<div class="question qt_checkbox">Send an ACORD certificate (Certificate holder request)
<a style="font-size:1em; font-weight:normal; text-decoration:underline; color:#616161;" rel="lightbox" href="#faq_accord_1" data-ob="lightbox">as described here</a>
<div id="faq_accord_1" style="display:none; min-height:150px !important;text-align:left; ">
<div id="lbx">
<p id="mwt">ACORD certificate (Certificate holder request)</p>
<p>The one-page ACORD certificate of insurance summarizes essential information about your insurance policy, such as coverage types, policy numbers, insurance limits, and effective and expiration dates. If your client or
landlord requires additional insured status under written contact with you we will issue the Acord certificate holder with additional insured status.</p>
</div>
</div><br>
</div>
</div>
<div id="MainContent_qr_511" class="questionBlock" style="display:block;">
<div class="answer at_checkbox"><input id="qId_511" name="qId_511" autocomplete="off" type="checkbox" onclick="validateAnswers(this);" value="True"></div>
<div class="question qt_checkbox">Add Authorized Person<br></div>
</div>
<div id="MainContent_qr_516" class="questionBlock" style="display:block;">
<div class="answer at_checkbox"><input id="qId_516" name="qId_516" autocomplete="off" type="checkbox" onclick="validateAnswers(this);" value="True"></div>
<div class="question qt_checkbox">Address Change<br></div>
</div>
<div id="MainContent_qr_521" class="questionBlock" style="display:block;">
<div class="answer at_checkbox"><input id="qId_521" name="qId_521" autocomplete="off" type="checkbox" onclick="validateAnswers(this);" value="True"></div>
<div class="question qt_checkbox">Business Name Change<br></div>
</div>
<div id="MainContent_qr_532" class="questionBlock" style="display:block;">
<div class="answer at_checkbox"><input id="qId_532" name="qId_532" autocomplete="off" type="checkbox" onclick="validateAnswers(this);" value="True"></div>
<div class="question qt_checkbox">Policy Document Request<br></div>
</div>
<div id="MainContent_qr_603" class="questionBlock" style="display:block;">
<div class="answer at_checkbox"><input id="qId_603" name="qId_603" autocomplete="off" type="checkbox" onclick="validateAnswers(this);" value="True"></div>
<div class="question qt_checkbox">Add a Waiver of Subrogation endorsement
<a style="font-size:1em; font-weight:normal; text-decoration:underline; color:#616161;" rel="lightbox" href="#faq_subrogation_1" data-ob="lightbox">as described here</a>
<div id="faq_subrogation_1" style="display:none; min-height:150px !important;">
<div id="lbx">
<p id="mwt">Modified Waiver of Transfer of Rights of Recovery Against Others to Us (Waiver of Subrogation)</p>
<p><b>General Liability: </b>Some client contracts or landlord lease agreements require your Commercial General Liability insurance to include a waiver of subrogation. If your contract or lease agreement requires this coverage
modification, you can include it on your policy for an additional fee.<br>This endorsement allows you to waive your rights against another party so long as you do so in writing prior to:<br>An offense arising out of your
business that caused a “personal and advertising injury” or an "occurrence" that caused "bodily injury" or "property damage".</p>
<p><b>Professional Liability: </b>Some client contracts require your Professional Liability insurance to include a waiver of subrogation. If your contract requires this coverage modification, you can include it on your policy
for an additional fee. This endorsement allows you to waive your rights of recovery, provided that Your waiver of Your rights is in writing and predates the first such Wrongful Act giving rise to the Claim resulting in payment
of Damages or Claim Expenses by Us. </p>
</div>
</div><br>
</div>
</div>
<div id="MainContent_qr_561" class="questionBlock" style="display:block;">
<div class="answer at_checkbox"><input id="qId_561" name="qId_561" autocomplete="off" type="checkbox" onclick="validateAnswers(this);" value="True"></div>
<div class="question qt_checkbox">Other<br></div>
</div>
<div id="MainContent_qr_648" class="questionBlock" style="display:block;">
<div class="answer at_checkbox"><input id="qId_648" name="qId_648" autocomplete="off" type="checkbox" onclick="validateAnswers(this);" value="True"></div>
<div class="question qt_checkbox">Submit Documents<br></div>
</div>
<div id="MainContent_qr_563" class="questionBlock" style="display:none;">
<div class="endCheckList"></div>
<div class="question qt_textzone">Questions/Comments (Please be as detailed as possible)<br></div>
<div class="answer at_textzone"><textarea id="qId_563" name="qId_563" maxlength="1000" onchange="echoStub(this);"></textarea></div>
</div>
<div id="MainContent_qr_466" class="questionBlock" style="display:none;">
<span class="questionTitle">Please indicate which of your client’s policies you would like to update:<br></span>
</div>
<div id="MainContent_qr_467" class="questionBlock" style="display:none;">
<div class="answer at_checkbox"><input id="qId_467" name="qId_467" autocomplete="off" type="checkbox" onclick="validateAnswers(this);" value="True"></div>
<div class="question qt_checkbox">Professional Liability (also known as Errors & Omissions)<br></div>
</div>
<div id="MainContent_qr_468" class="questionBlock" style="display:none;">
<div class="answer at_checkbox"><input id="qId_468" name="qId_468" autocomplete="off" type="checkbox" onclick="validateAnswers(this);" value="True"></div>
<div class="question qt_checkbox">General Liability<br></div>
</div>
<div id="MainContent_qr_496" class="questionBlock" style="display:none;">
<div class="endCheckList"></div><span class="questionTitle">or<br></span>
</div>
<div id="MainContent_qr_469" class="questionBlock" style="display:none;">
<div class="answer at_checkbox"><input id="qId_469" name="qId_469" autocomplete="off" type="checkbox" onclick="validateAnswers(this);" value="True"></div>
<div class="question qt_checkbox">Business Owners Policy<br></div>
</div>
<div id="MainContent_qr_702" class="questionBlock" style="display:none;">
<div class="endCheckList"></div>
<div class="question qt_textzone">Please provide the name and address of the entity requesting the waiver of subrogation.<br></div>
<div class="answer at_textzone"><textarea id="qId_702" name="qId_702" maxlength="1000" onchange="echoStub(this);"></textarea></div>
</div>
<div id="MainContent_qr_616" class="questionBlock" style="display:none;">
<span class="questionTitle">What is your client’s relationship with this party?<br></span>
</div>
<div id="MainContent_qr_617" class="questionBlock" style="display:none;">
<div class="answer at_radio"><input id="617_616" type="radio" autocomplete="off" value="Client" name="qId_616" onclick="validateAnswers(this);"><label id="l_617" class="rOpt" for="617_616">Client</label></div>
</div>
<div id="MainContent_qr_618" class="questionBlock" style="display:none;">
<div class="answer at_radio"><input id="618_616" type="radio" autocomplete="off" value="Landlord" name="qId_616" onclick="validateAnswers(this);"><label id="l_618" class="rOpt" for="618_616">Landlord</label></div>
</div>
<div id="MainContent_qr_619" class="questionBlock" style="display:none;">
<div class="answer at_radio"><input id="619_616" type="radio" autocomplete="off" value="Other, please explain" name="qId_616" onclick="validateAnswers(this);"><label id="l_619" class="rOpt" for="619_616">Other, please explain</label>
</div>
</div>
<div id="MainContent_qr_620" class="questionBlock" style="display:none;">
<div class="question qt_textzone">Please describe the professional service your client will provide to this party <i>(Limit 1000 Characters)</i><br></div>
<div class="answer at_textzone"><textarea id="qId_620" name="qId_620" maxlength="1000" onchange="echoStub(this);"></textarea></div>
</div>
<div id="MainContent_qr_610" class="questionBlock" style="display:none;">
<div class="question qt_textzone">Provide a brief description of your client’s professional services (please provide more detail than “Consulting”, a brief description will expedite handling).<br></div>
<div class="answer at_textzone"><textarea id="qId_610" name="qId_610" maxlength="1000" onchange="echoStub(this);"></textarea></div>
</div>
<div id="MainContent_qr_621" class=" hidden hidden questionBlock" style="display:none;">
<p>If you are an Architect, Engineer or Design professional we will require a copy of your contract with the waiver of subrogation insurance requirement and the detailed statement of work. Please email this to
<a href="mailto:contact@hiscox.com">contact@hiscox.com</a>.</p>
</div>
<div id="MainContent_qr_482" class="questionBlock" style="display:none;">
<span class="questionTitle">For the waiver of subrogation endorsement, a 10% premium charge will be applied to the policy. Please confirm:<br></span>
</div>
<div id="MainContent_qr_604" class=" hidden hidden questionBlock" style="display:none;">
<span class="questionTitle">Please Confirm:<br></span>
</div>
<div id="MainContent_qr_605" class="questionBlock" style="display:none;">
<div class="answer at_checkbox"><input id="qId_605" name="qId_605" autocomplete="off" type="checkbox" onclick="validateAnswers(this);" value="True"></div>
<div class="question qt_checkbox">I give Hiscox Insurance Company, Inc. my consent to automatically charge any additional premium using the credit card on my client’s policy.<br></div>
</div>
</div>
</div>
<div id="MainContent_sctn3" class="SectionContainer" style="display:none;">
<div class="cnt-subsctn">
<div class="top">
<div class="right">
<div class="left">
<div class="middle"></div>
</div>
</div>
</div>
<div class="middle-content">
<div class="page-heading2">
<h1 class="page-heading-h1">Additional Insured Information </h1>
</div>
<div class="clear"></div>
</div>
<div class="bottom clear-both">
<div class="right">
<div class="left">
<div class="middle"></div>
</div>
</div>
</div>
</div>
<div class="_form">
<div id="MainContent_qr_488" class="questionBlock" style="display:none;">
<div class="answer at_radio"><input id="488_475" type="radio" autocomplete="off" value="Landlord" name="qId_475" onclick="validateAnswers(this);"><label id="l_488" class="rOpt" for="488_475">Landlord</label></div>
</div>
<div id="MainContent_qr_489" class="questionBlock" style="display:none;">
<div class="answer at_radio"><input id="489_475" type="radio" autocomplete="off" value="Loss payee" name="qId_475" onclick="validateAnswers(this);"><label id="l_489" class="rOpt" for="489_475">Loss payee</label></div>
</div>
<div id="MainContent_qr_498" class="questionBlock" style="display:none;">
<span class="questionTitle">Note: Please type the additional insured’s name exactly as you want it to appear on the documentation. Only one client name is allowed per Additional Insured endorsement. Multiple client names or client
entities will be listed on separate endorsements.<br></span>
</div>
<div id="MainContent_qr_499" class="questionBlock" style="display:none;">
<span class="questionTitle">Note: Please type the additional insured’s name exactly as you want it to appear on the documentation. Multiple landlord entity names for the same address may be listed on the same endorsement.<br></span>
</div>
<div id="MainContent_qr_494" class="questionBlock" style="display:none;">
<div class="question qt_text">Name of Additional Insured <i>(entity will be listed as a certificate holder on the ACORD)</i><br></div>
<div class="answer at_"><input id="qId_494" name="qId_494" type="text" value="" maxlength="100" onchange="echoStub(this);" onkeypress="return noenter(event)"></div>
</div>
<div id="MainContent_qr_470" class="questionBlock" style="display:none;">
<div class="question qt_text">Street<br></div>
<div class="answer at_"><input id="qId_470" name="qId_470" type="text" value="" maxlength="500" onchange="echoStub(this);" onkeypress="return noenter(event)"></div>
</div>
<div id="MainContent_qr_471" class="questionBlock" style="display:none;">
<div class="question qt_text">Secondary street (optional)<br></div>
<div class="answer at_"><input id="qId_471" name="qId_471" type="text" value="" maxlength="500" onchange="echoStub(this);" onkeypress="return noenter(event)"></div>
</div>
<div id="MainContent_qr_472" class="questionBlock" style="display:none;">
<div class="question qt_text">City<br></div>
<div class="answer at_"><input id="qId_472" name="qId_472" type="text" value="" maxlength="500" onchange="echoStub(this);" onkeypress="return noenter(event)"></div>
</div>
<div id="MainContent_qr_13" class="questionBlock" style="display:none;">
<div class="question qt_dropdown">State:<br></div>
<div class="answer at_"><select id="qId_13" name="qId_13" autocomplete="off" onchange="validateAnswers(this);">
<option>Please Select</option>
<option value="ALABAMA">ALABAMA</option>
<option value="ALASKA">ALASKA</option>
<option value="ARIZONA">ARIZONA</option>
<option value="ARKANSAS">ARKANSAS</option>
<option value="CALIFORNIA">CALIFORNIA</option>
<option value="COLORADO">COLORADO</option>
<option value="CONNECTICUT">CONNECTICUT</option>
<option value="DELAWARE">DELAWARE</option>
<option value="DISTRICT OF COLUMBIA">DISTRICT OF COLUMBIA</option>
<option value="FLORIDA">FLORIDA</option>
<option value="GEORGIA">GEORGIA</option>
<option value="HAWAII">HAWAII</option>
<option value="IDAHO">IDAHO</option>
<option value="ILLINOIS">ILLINOIS</option>
<option value="INDIANA">INDIANA</option>
<option value="IOWA">IOWA</option>
<option value="KANSAS">KANSAS</option>
<option value="KENTUCKY">KENTUCKY</option>
<option value="LOUISIANA">LOUISIANA</option>
<option value="MAINE">MAINE</option>
<option value="MARYLAND">MARYLAND</option>
<option value="MASSACHUSETTS">MASSACHUSETTS</option>
<option value="MICHIGAN">MICHIGAN</option>
<option value="MINNESOTA">MINNESOTA</option>
<option value="MISSISSIPPI">MISSISSIPPI</option>
<option value="MISSOURI">MISSOURI</option>
<option value="MONTANA">MONTANA</option>
<option value="NEBRASKA">NEBRASKA</option>
<option value="NEVADA">NEVADA</option>
<option value="NEW HAMPSHIRE">NEW HAMPSHIRE</option>
<option value="NEW JERSEY">NEW JERSEY</option>
<option value="NEW MEXICO">NEW MEXICO</option>
<option value="NEW YORK">NEW YORK</option>
<option value="NORTH CAROLINA">NORTH CAROLINA</option>
<option value="NORTH DAKOTA">NORTH DAKOTA</option>
<option value="OHIO">OHIO</option>
<option value="OKLAHOMA">OKLAHOMA</option>
<option value="OREGON">OREGON</option>
<option value="PENNSYLVANIA">PENNSYLVANIA</option>
<option value="RHODE ISLAND">RHODE ISLAND</option>
<option value="SOUTH CAROLINA">SOUTH CAROLINA</option>
<option value="SOUTH DAKOTA">SOUTH DAKOTA</option>
<option value="TENNESSEE">TENNESSEE</option>
<option value="TEXAS">TEXAS</option>
<option value="UTAH">UTAH</option>
<option value="VERMONT">VERMONT</option>
<option value="VIRGINIA">VIRGINIA</option>
<option value="WASHINGTON">WASHINGTON</option>
<option value="WEST VIRGINIA">WEST VIRGINIA</option>
<option value="WISCONSIN">WISCONSIN</option>
<option value="WYOMING">WYOMING</option>
</select></div>
</div>
<div id="MainContent_qr_474" class="questionBlock" style="display:none;">
<div class="question qt_text">ZIP code <br><br></div>
<div class="answer at_"><input id="qId_474" name="qId_474" type="text" value="" maxlength="500" onchange="echoStub(this);" onkeypress="return noenter(event)"></div>
</div>
<div id="MainContent_qr_612" class="questionBlock" style="display:none;">
<span class="questionTitle">Description of operations:<br></span>
</div>
<div id="MainContent_qr_611" class="questionBlock" style="display:none;">
<div class="answer at_checkbox"><input id="qId_611" name="qId_611" autocomplete="off" type="checkbox" onclick="validateAnswers(this);" value="True"></div>
<div class="question qt_checkbox">Please click here if your client or landlord requires specific language on the ACORD certificate. You understand and agree any language entered in the description of operations wording field does not
alter or change any of the policy's terms and conditions.<br></div>
</div>
<div id="MainContent_qr_606" class="questionBlock" style="display:none;">
<div class="endCheckList"></div>
<div class="question qt_textzone">Description of operations wording - some clients ask for specific language to be added to the ACORD certificate to meet their requirements. If your client has requested this, please enter it here. If
not, please leave this section blank.<br></div>
<div class="answer at_textzone"><textarea id="qId_606" name="qId_606" maxlength="<822" onchange="echoStub(this);"></textarea></div>
</div>
<div id="MainContent_qr_476" class="questionBlock" style="display:none;">
<div class="question qt_textzone">Please provide a description of the services you will perform for this client:<br></div>
<div class="answer at_textzone"><textarea id="qId_476" name="qId_476" maxlength="1000" onchange="echoStub(this);"></textarea></div>
</div>
<div id="MainContent_qr_477" class="questionBlock" style="display:none;">
<div class="question qt_textzone">Please include a description of leased property and estimated value.<br></div>
<div class="answer at_textzone"><textarea id="qId_477" name="qId_477" maxlength="1000" onchange="echoStub(this);"></textarea></div>
</div>
<div id="MainContent_qr_478" class="questionBlock" style="display:none;">
<div class="question qt_textzone">Please describe your relationship with the third party and why an Additional Insured status is being requested.<br></div>
<div class="answer at_textzone"><textarea id="qId_478" name="qId_478" maxlength="1000" onchange="echoStub(this);"></textarea></div>
</div>
</div>
</div>
<div id="MainContent_sctn4" class="SectionContainer" style="display:none;">
<div class="cnt-subsctn">
<div class="top">
<div class="right">
<div class="left">
<div class="middle"></div>
</div>
</div>
</div>
<div class="middle-content">
<div class="page-heading2">
<h1 class="page-heading-h1">Acord Request </h1>
</div>
<div class="clear"></div>
</div>
<div class="bottom clear-both">
<div class="right">
<div class="left">
<div class="middle"></div>
</div>
</div>
</div>
</div>
<div class="_form">
<div id="MainContent_qr_479" class="questionBlock" style="display:none;">
<div class="question qt_text">Certificate holder (the name of the business requesting a certificate of insurance) <br><br></div>
<div class="answer at_"><input id="qId_479" name="qId_479" type="text" value="" maxlength="500" onchange="echoStub(this);" onkeypress="return noenter(event)"></div>
</div>
<div id="MainContent_qr_500" class="questionBlock" style="display:none;">
<div class="question qt_text">Street<br></div>
<div class="answer at_"><input id="qId_500" name="qId_500" type="text" value="" maxlength="500" onchange="echoStub(this);" onkeypress="return noenter(event)"></div>
</div>
<div id="MainContent_qr_501" class="questionBlock" style="display:none;">
<div class="question qt_text">Secondary street (optional)<br></div>
<div class="answer at_"><input id="qId_501" name="qId_501" type="text" value="" maxlength="500" onchange="echoStub(this);" onkeypress="return noenter(event)"></div>
</div>
<div id="MainContent_qr_502" class="questionBlock" style="display:none;">
<div class="question qt_text">City<br></div>
<div class="answer at_"><input id="qId_502" name="qId_502" type="text" value="" maxlength="500" onchange="echoStub(this);" onkeypress="return noenter(event)"></div>
</div>
<div id="MainContent_qr_506" class="questionBlock" style="display:none;">
<div class="question qt_dropdown">State:<br></div>
<div class="answer at_"><select id="qId_506" name="qId_506" autocomplete="off" onchange="validateAnswers(this);">
<option>Please Select</option>
<option value="ALABAMA">ALABAMA</option>
<option value="ALASKA">ALASKA</option>
<option value="ARIZONA">ARIZONA</option>
<option value="ARKANSAS">ARKANSAS</option>
<option value="CALIFORNIA">CALIFORNIA</option>
<option value="COLORADO">COLORADO</option>
<option value="CONNECTICUT">CONNECTICUT</option>
<option value="DELAWARE">DELAWARE</option>
<option value="DISTRICT OF COLUMBIA">DISTRICT OF COLUMBIA</option>
<option value="FLORIDA">FLORIDA</option>
<option value="GEORGIA">GEORGIA</option>
<option value="HAWAII">HAWAII</option>
<option value="IDAHO">IDAHO</option>
<option value="ILLINOIS">ILLINOIS</option>
<option value="INDIANA">INDIANA</option>
<option value="IOWA">IOWA</option>
<option value="KANSAS">KANSAS</option>
<option value="KENTUCKY">KENTUCKY</option>
<option value="LOUISIANA">LOUISIANA</option>
<option value="MAINE">MAINE</option>
<option value="MARYLAND">MARYLAND</option>
<option value="MASSACHUSETTS">MASSACHUSETTS</option>
<option value="MICHIGAN">MICHIGAN</option>
<option value="MINNESOTA">MINNESOTA</option>
<option value="MISSISSIPPI">MISSISSIPPI</option>
<option value="MISSOURI">MISSOURI</option>
<option value="MONTANA">MONTANA</option>
<option value="NEBRASKA">NEBRASKA</option>
<option value="NEVADA">NEVADA</option>
<option value="NEW HAMPSHIRE">NEW HAMPSHIRE</option>
<option value="NEW JERSEY">NEW JERSEY</option>
<option value="NEW MEXICO">NEW MEXICO</option>
<option value="NEW YORK">NEW YORK</option>
<option value="NORTH CAROLINA">NORTH CAROLINA</option>
<option value="NORTH DAKOTA">NORTH DAKOTA</option>
<option value="OHIO">OHIO</option>
<option value="OKLAHOMA">OKLAHOMA</option>
<option value="OREGON">OREGON</option>
<option value="PENNSYLVANIA">PENNSYLVANIA</option>
<option value="RHODE ISLAND">RHODE ISLAND</option>
<option value="SOUTH CAROLINA">SOUTH CAROLINA</option>
<option value="SOUTH DAKOTA">SOUTH DAKOTA</option>
<option value="TENNESSEE">TENNESSEE</option>
<option value="TEXAS">TEXAS</option>
<option value="UTAH">UTAH</option>
<option value="VERMONT">VERMONT</option>
<option value="VIRGINIA">VIRGINIA</option>
<option value="WASHINGTON">WASHINGTON</option>
<option value="WEST VIRGINIA">WEST VIRGINIA</option>
<option value="WISCONSIN">WISCONSIN</option>
<option value="WYOMING">WYOMING</option>
</select></div>
</div>
<div id="MainContent_qr_504" class="questionBlock" style="display:none;">
<div class="question qt_text">ZIP code <br><br></div>
<div class="answer at_"><input id="qId_504" name="qId_504" type="text" value="" maxlength="500" onchange="echoStub(this);" onkeypress="return noenter(event)"></div>
</div>
<div id="MainContent_qr_614" class="questionBlock" style="display:none;">
<span class="questionTitle">Description of operations:<br></span>
</div>
<div id="MainContent_qr_613" class="questionBlock" style="display:none;">
<div class="answer at_checkbox"><input id="qId_613" name="qId_613" autocomplete="off" type="checkbox" onclick="validateAnswers(this);" value="True"></div>
<div class="question qt_checkbox">Please click here if your client or landlord requires specific language on the ACORD certificate. You understand and agree any language entered in the description of operations wording field does not
alter or change any of the policy's terms and conditions.<br></div>
</div>
<div id="MainContent_qr_480" class="questionBlock" style="display:none;">
<div class="endCheckList"></div>
<div class="question qt_textzone">Description of operations wording - some clients ask for specific language to be added to the ACORD certificate to meet their requirements. If your client has requested this, please enter it here. If
not, please leave this section blank.<br></div>
<div class="answer at_textzone"><textarea id="qId_480" name="qId_480" maxlength="<822" onchange="echoStub(this);"></textarea></div>
</div>
</div>
</div>
<div id="MainContent_sctn12" class="SectionContainer" style="display:none;">
<div class="cnt-subsctn">
<div class="top">
<div class="right">
<div class="left">
<div class="middle"></div>
</div>
</div>
</div>
<div class="middle-content">
<div class="page-heading2">
<h1 class="page-heading-h1">Add Authorized Person </h1>
</div>
<div class="clear"></div>
</div>
<div class="bottom clear-both">
<div class="right">
<div class="left">
<div class="middle"></div>
</div>
</div>
</div>
</div>
<div class="_form">
<div id="MainContent_qr_512" class="questionBlock" style="display:none;">
<div class="question qt_text">Authorized Person Name<br></div>
<div class="answer at_"><input id="qId_512" name="qId_512" type="text" value="" maxlength="500" onchange="echoStub(this);" onkeypress="return noenter(event)"></div>
</div>
<div id="MainContent_qr_647" class="questionBlock" style="display:none;">
<div class="question qt_text">Authorized Person Last Name<br></div>
<div class="answer at_"><input id="qId_647" name="qId_647" type="text" value="" maxlength="500" onchange="echoStub(this);" onkeypress="return noenter(event)"></div>
</div>
<div id="MainContent_qr_513" class="questionBlock" style="display:none;">
<div class="question qt_text">Role<br></div>
<div class="answer at_"><input id="qId_513" name="qId_513" type="text" value="" maxlength="500" onchange="echoStub(this);" onkeypress="return noenter(event)"></div>
</div>
<div id="MainContent_qr_514" class="questionBlock" style="display:none;">
<div class="question qt_text">Phone Number<br></div>
<div class="answer at_"><input id="qId_514" name="qId_514" type="text" value="" maxlength="500" onchange="echoStub(this);" onkeypress="return noenter(event)"></div>
</div>
<div id="MainContent_qr_515" class="questionBlock" style="display:none;">
<div class="question qt_text">Email Address<br></div>
<div class="answer at_"><input id="qId_515" name="qId_515" type="text" value="" maxlength="500" onchange="echoStub(this);" onkeypress="return noenter(event)"></div>
</div>
</div>
</div>
<div id="MainContent_sctn13" class="SectionContainer" style="display:none;">
<div class="cnt-subsctn">
<div class="top">
<div class="right">
<div class="left">
<div class="middle"></div>
</div>
</div>
</div>
<div class="middle-content">
<div class="page-heading2">
<h1 class="page-heading-h1">Address Change </h1>
</div>
<div class="clear"></div>
</div>
<div class="bottom clear-both">
<div class="right">
<div class="left">
<div class="middle"></div>
</div>
</div>
</div>
</div>
<div class="_form">
<div id="MainContent_qr_543" class="questionBlock" style="display:none;">
<div class="question qt_text">Street<br></div>
<div class="answer at_"><input id="qId_543" name="qId_543" type="text" value="" maxlength="500" onchange="echoStub(this);" onkeypress="return noenter(event)"></div>
</div>
<div id="MainContent_qr_544" class="questionBlock" style="display:none;">
<div class="question qt_text">Secondary street (optional)<br></div>
<div class="answer at_"><input id="qId_544" name="qId_544" type="text" value="" maxlength="500" onchange="echoStub(this);" onkeypress="return noenter(event)"></div>
</div>
<div id="MainContent_qr_545" class="questionBlock" style="display:none;">
<div class="question qt_text">City<br></div>
<div class="answer at_"><input id="qId_545" name="qId_545" type="text" value="" maxlength="500" onchange="echoStub(this);" onkeypress="return noenter(event)"></div>
</div>
<div id="MainContent_qr_546" class="questionBlock" style="display:none;">
<div class="question qt_dropdown">State:<br></div>
<div class="answer at_"><select id="qId_546" name="qId_546" autocomplete="off" onchange="validateAnswers(this);">
<option>Please Select</option>
<option value="ALABAMA">ALABAMA</option>
<option value="ALASKA">ALASKA</option>
<option value="ARIZONA">ARIZONA</option>
<option value="ARKANSAS">ARKANSAS</option>
<option value="CALIFORNIA">CALIFORNIA</option>
<option value="COLORADO">COLORADO</option>
<option value="CONNECTICUT">CONNECTICUT</option>
<option value="DELAWARE">DELAWARE</option>
<option value="DISTRICT OF COLUMBIA">DISTRICT OF COLUMBIA</option>
<option value="FLORIDA">FLORIDA</option>
<option value="GEORGIA">GEORGIA</option>
<option value="HAWAII">HAWAII</option>
<option value="IDAHO">IDAHO</option>
<option value="ILLINOIS">ILLINOIS</option>
<option value="INDIANA">INDIANA</option>
<option value="IOWA">IOWA</option>
<option value="KANSAS">KANSAS</option>
<option value="KENTUCKY">KENTUCKY</option>
<option value="LOUISIANA">LOUISIANA</option>
<option value="MAINE">MAINE</option>
<option value="MARYLAND">MARYLAND</option>
<option value="MASSACHUSETTS">MASSACHUSETTS</option>
<option value="MICHIGAN">MICHIGAN</option>
<option value="MINNESOTA">MINNESOTA</option>
<option value="MISSISSIPPI">MISSISSIPPI</option>
<option value="MISSOURI">MISSOURI</option>
<option value="MONTANA">MONTANA</option>
<option value="NEBRASKA">NEBRASKA</option>
<option value="NEVADA">NEVADA</option>
<option value="NEW HAMPSHIRE">NEW HAMPSHIRE</option>
<option value="NEW JERSEY">NEW JERSEY</option>
<option value="NEW MEXICO">NEW MEXICO</option>
<option value="NEW YORK">NEW YORK</option>
<option value="NORTH CAROLINA">NORTH CAROLINA</option>
<option value="NORTH DAKOTA">NORTH DAKOTA</option>
<option value="OHIO">OHIO</option>
<option value="OKLAHOMA">OKLAHOMA</option>
<option value="OREGON">OREGON</option>
<option value="PENNSYLVANIA">PENNSYLVANIA</option>
<option value="RHODE ISLAND">RHODE ISLAND</option>
<option value="SOUTH CAROLINA">SOUTH CAROLINA</option>
<option value="SOUTH DAKOTA">SOUTH DAKOTA</option>
<option value="TENNESSEE">TENNESSEE</option>
<option value="TEXAS">TEXAS</option>
<option value="UTAH">UTAH</option>
<option value="VERMONT">VERMONT</option>
<option value="VIRGINIA">VIRGINIA</option>
<option value="WASHINGTON">WASHINGTON</option>
<option value="WEST VIRGINIA">WEST VIRGINIA</option>
<option value="WISCONSIN">WISCONSIN</option>
<option value="WYOMING">WYOMING</option>
</select></div>
</div>
<div id="MainContent_qr_547" class="questionBlock" style="display:none;">
<div class="question qt_text">ZIP code <br><br></div>
<div class="answer at_"><input id="qId_547" name="qId_547" type="text" value="" maxlength="500" onchange="echoStub(this);" onkeypress="return noenter(event)"></div>
</div>
<div id="MainContent_qr_518" class="questionBlock" style="display:none;">
<div class="question qt_text">Square feet occupied at this address<br></div>
<div class="answer at_"><input id="qId_518" name="qId_518" type="text" value="" maxlength="500" onchange="echoStub(this);" onkeypress="return noenter(event)"></div>
</div>
<div id="MainContent_qr_519" class="questionBlock" style="display:none;">
<div class="question qt_text">Total number of business locations<br></div>
<div class="answer at_"><input id="qId_519" name="qId_519" type="text" value="" maxlength="500" onchange="echoStub(this);" onkeypress="return noenter(event)"></div>
</div>
<div id="MainContent_qr_520" class="questionBlock" style="display:none;">
<div class="question qt_textzone">Any change in business services, if yes please describe.<br></div>
<div class="answer at_textzone"><textarea id="qId_520" name="qId_520" maxlength="1000" onchange="echoStub(this);"></textarea></div>
</div>
</div>
</div>
<div id="MainContent_sctn14" class="SectionContainer" style="display:none;">
<div class="cnt-subsctn">
<div class="top">
<div class="right">
<div class="left">
<div class="middle"></div>
</div>
</div>
</div>
<div class="middle-content">
<div class="page-heading2">
<h1 class="page-heading-h1">Business Name Change </h1>
</div>
<div class="clear"></div>
</div>
<div class="bottom clear-both">
<div class="right">
<div class="left">
<div class="middle"></div>
</div>
</div>
</div>
</div>
<div class="_form">
<div id="MainContent_qr_522" class="questionBlock" style="display:none;">
<span class="questionTitle">Reason for change<br></span>
</div>
<div id="MainContent_qr_523" class="questionBlock" style="display:none;">
<div class="answer at_checkbox"><input id="qId_523" name="qId_523" autocomplete="off" type="checkbox" onclick="validateAnswers(this);" value="True"></div>
<div class="question qt_checkbox">Typographical Error<br></div>
</div>
<div id="MainContent_qr_524" class="questionBlock" style="display:none;">
<div class="answer at_checkbox"><input id="qId_524" name="qId_524" autocomplete="off" type="checkbox" onclick="validateAnswers(this);" value="True"></div>
<div class="question qt_checkbox">Other, please explain<br></div>
</div>
<div id="MainContent_qr_565" class="questionBlock" style="display:none;">
<div class="endCheckList"></div>
<div class="question qt_text">Reason for change explanation<br></div>
<div class="answer at_textbox"><input id="qId_565" name="qId_565" type="text" value="" maxlength="500" onchange="echoStub(this);" onkeypress="return noenter(event)"></div>
</div>
<div id="MainContent_qr_525" class="questionBlock" style="display:none;">
<span class="questionTitle">Has your business experienced any of the following?<br></span>
</div>
<div id="MainContent_qr_526" class="questionBlock" style="display:none;">
<div class="question qt_radiocluster">Adverse financial event<br></div>
<div class="answer at_radiocluster"><input id="000_526" type="radio" autocomplete="off" value="Yes" name="qId_526" onclick="validateAnswers(this);"><label id="l_000" class="rOpt" for="000_526">Yes</label><input id="001_526"
type="radio" autocomplete="off" value="No" name="qId_526" onclick="validateAnswers(this);"><label id="l_001" class="rOpt" for="001_526">No</label></div>
</div>
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<div class="question qt_radiocluster">Change in services<br></div>
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<div id="MainContent_qr_530" class="questionBlock" style="display:none;">
<div class="question qt_radiocluster">Change in control<br></div>
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<div id="MainContent_qr_528" class="questionBlock" style="display:none;">
<div class="question qt_radiocluster">Merger, acquisition, or other change in ownership<br></div>
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<div id="MainContent_qr_531" class="questionBlock" style="display:none;">
<div class="endCheckList"></div>
<div class="question qt_text">Business Name<br></div>
<div class="answer at_"><input id="qId_531" name="qId_531" type="text" value="" maxlength="500" onchange="echoStub(this);" onkeypress="return noenter(event)"></div>
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</div>
</div>
<div id="MainContent_sctn15" class="SectionContainer" style="display:none;">
<div class="cnt-subsctn">
<div class="top">
<div class="right">
<div class="left">
<div class="middle"></div>
</div>
</div>
</div>
<div class="middle-content">
<div class="page-heading2">
<h1 class="page-heading-h1">Policy Document Request </h1>
</div>
<div class="clear"></div>
</div>
<div class="bottom clear-both">
<div class="right">
<div class="left">
<div class="middle"></div>
</div>
</div>
</div>
</div>
<div class="_form">
<div id="MainContent_qr_533" class=" hidden hidden questionBlock" style="display:none;">
<span class="questionTitle">Reason for Request<br></span>
</div>
<div id="MainContent_qr_534" class="questionBlock" style="display:none;">
<div class="answer at_radio"><input id="534_533" type="radio" checked="checked" autocomplete="off" value="Resend Policy purchase documents" name="qId_533" onclick="validateAnswers(this);"><label id="l_534" class="rOpt"
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</div>
<div id="MainContent_qr_535" class="questionBlock" style="display:none;">
<div class="answer at_radio"><input id="535_533" type="radio" autocomplete="off" value="Other" name="qId_533" onclick="validateAnswers(this);"><label id="l_535" class="rOpt" for="535_533">Other</label></div>
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<div id="MainContent_qr_536" class="questionBlock" style="display:none;">
<div class="question qt_textzone">Please advise what document/documents are requested<br></div>
<div class="answer at_textzone"><textarea id="qId_536" name="qId_536" maxlength="1000" onchange="echoStub(this);"></textarea></div>
</div>
</div>
</div>
<div id="MainContent_sctn16" class="SectionContainer">
<div class="cnt-subsctn">
<div class="top">
<div class="right">
<div class="left">
<div class="middle"></div>
</div>
</div>
</div>
<div class="middle-content">
<div class="page-heading2">
<h1 class="page-heading-h1">Agent & Partner Servicing Requests </h1>
</div>
<div class="clear"></div>
</div>
<div class="bottom clear-both">
<div class="right">
<div class="left">
<div class="middle"></div>
</div>
</div>
</div>
</div>
<div class="_form">
<div id="MainContent_qr_716" class=" hidden hidden questionBlock" style="display:block;">
<span class="questionTitle">Please select one or more of the following options<br></span>
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<div id="MainContent_qr_541" class=" hidden hidden questionBlock" style="display:none;">
<div class="question qt_text">Partner<br></div>
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<div id="MainContent_qr_542" class=" hidden hidden questionBlock" style="display:none;">
<div class="question qt_text">Agent ID<br></div>
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<div class="question qt_checkbox">Request a Loss Run<br></div>
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<div class="question qt_checkbox">Missing Credit for Policy Sale or Commission<br></div>
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<div id="MainContent_qr_712" class="questionBlock" style="display:block;">
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<div class="middle-content">
<div class="page-heading2">
<h1 class="page-heading-h1">Request a Loss Run </h1>
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<div class="right">
<div class="left">
<div class="middle"></div>
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<div class="middle-content">
<div class="page-heading2">
<h1 class="page-heading-h1">Missing Credit for Policy Sale or Commission </h1>
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<div class="bottom clear-both">
<div class="right">
<div class="left">
<div class="middle"></div>
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<div class="question qt_textzone">Any other additional comments<br></div>
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<div class="left">
<div class="middle"></div>
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<div class="middle-content">
<div class="page-heading2">
<h1 class="page-heading-h1">Request Broker or Agent of Record Change </h1>
</div>
<div class="clear"></div>
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<div class="bottom clear-both">
<div class="right">
<div class="left">
<div class="middle"></div>
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<a href="/downloads/Broker of Record Change Form - Acord 36.pdf" download="" target="_blank">Broker of Record Change Form</a>
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<div id="MainContent_qr_715" class="questionBlock" style="display:none;">
<span class="questionTitle">
<br>Please upload your completed request form. We will contact you if we need further information.<br></span>
</div>
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<div class="cnt-subsctn">
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<div class="right">
<div class="left">
<div class="middle"></div>
</div>
</div>
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<div class="middle-content">
<div class="page-heading2">
<h1 class="page-heading-h1">
</h1>
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<div class="clear"></div>
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<div class="bottom clear-both">
<div class="right">
<div class="left">
<div class="middle"></div>
</div>
</div>
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<div class="_form">
<div id="MainContent_qr_481" class=" hidden hidden questionBlock" style="display:block;">
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<div id="MainContent_qr_650" class=" hidden hidden questionBlock" style="display:block;">
<div class="question qt_text">Uploaded documents<br></div>
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<div id="MainContent_qr_645" class="questionBlock" style="display:none;">
<span class="questionTitle">You will receive a set of your most recent Hiscox policy documents via email within one business day.<br></span>
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<div id="MainContent_qr_651" class="questionBlock" style="display:none;">
<div class="question qt_text">Hiscox Agent<br></div>
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<div id="MainContent_qr_652" class="questionBlock" style="display:none;">
<span style="font-size:14px;">If applicable, please enter the name of the Hiscox Agent who requested these documents.</span><br><br><br>
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<div class="question qt_textzone">Please describe briefly what you would like us to do with these submitted documents. <br>
<br>If this is in response to a request from us, please provide a brief description regarding the reason we asked for these documents (as this request will be processed by a different individual than the one you spoke to or heard
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<br>Please limit your response to 1000 characters<br>
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Policy Management 1-866-739-0727 The highlighted questions contain errors. Please review and amend. This site allows you to quickly request servicing on your client’s policy or submit a general inquiry. Most requests will be responded to within 1 business day. If you have any questions or need to speak with us regarding your request, please contact us at 1-866-739-0727, Mon – Fri from 7 am to 10 pm ET. YOUR INFORMATION First Name* Last Name* Hiscox Partner/Wholesaler Affiliation Name Agent ID Email Address Phone Number Policy Servicing Requests Agent & Partner Servicing Requests Your Hiscox partner/wholesaler affiliation Email address Phone number Please provide any special wording required on the certificate. POLICY SERVICING REQUESTS Named insured (Business name) Hiscox policy number You can find the policy number on the upper right hand corner of the policy documents or emails we've sent you. The policy number will follow one of these formats: UDC-1234567-CGL-99 UDC-1234567-EO-99 UDC-1234567-BOP-99 Please select one or more of the following options Issue an Additional Insured an ACORD certificate Send an ACORD certificate (Certificate holder request) as described here ACORD certificate (Certificate holder request) The one-page ACORD certificate of insurance summarizes essential information about your insurance policy, such as coverage types, policy numbers, insurance limits, and effective and expiration dates. If your client or landlord requires additional insured status under written contact with you we will issue the Acord certificate holder with additional insured status. Add Authorized Person Address Change Business Name Change Policy Document Request Add a Waiver of Subrogation endorsement as described here Modified Waiver of Transfer of Rights of Recovery Against Others to Us (Waiver of Subrogation) General Liability: Some client contracts or landlord lease agreements require your Commercial General Liability insurance to include a waiver of subrogation. If your contract or lease agreement requires this coverage modification, you can include it on your policy for an additional fee. This endorsement allows you to waive your rights against another party so long as you do so in writing prior to: An offense arising out of your business that caused a “personal and advertising injury” or an "occurrence" that caused "bodily injury" or "property damage". Professional Liability: Some client contracts require your Professional Liability insurance to include a waiver of subrogation. If your contract requires this coverage modification, you can include it on your policy for an additional fee. This endorsement allows you to waive your rights of recovery, provided that Your waiver of Your rights is in writing and predates the first such Wrongful Act giving rise to the Claim resulting in payment of Damages or Claim Expenses by Us. Other Submit Documents Questions/Comments (Please be as detailed as possible) Please indicate which of your client’s policies you would like to update: Professional Liability (also known as Errors & Omissions) General Liability or Business Owners Policy Please provide the name and address of the entity requesting the waiver of subrogation. What is your client’s relationship with this party? Client Landlord Other, please explain Please describe the professional service your client will provide to this party (Limit 1000 Characters) Provide a brief description of your client’s professional services (please provide more detail than “Consulting”, a brief description will expedite handling). If you are an Architect, Engineer or Design professional we will require a copy of your contract with the waiver of subrogation insurance requirement and the detailed statement of work. Please email this to contact@hiscox.com. For the waiver of subrogation endorsement, a 10% premium charge will be applied to the policy. Please confirm: Please Confirm: I give Hiscox Insurance Company, Inc. my consent to automatically charge any additional premium using the credit card on my client’s policy. ADDITIONAL INSURED INFORMATION Landlord Loss payee Note: Please type the additional insured’s name exactly as you want it to appear on the documentation. Only one client name is allowed per Additional Insured endorsement. Multiple client names or client entities will be listed on separate endorsements. Note: Please type the additional insured’s name exactly as you want it to appear on the documentation. Multiple landlord entity names for the same address may be listed on the same endorsement. Name of Additional Insured (entity will be listed as a certificate holder on the ACORD) Street Secondary street (optional) City State: Please SelectALABAMAALASKAARIZONAARKANSASCALIFORNIACOLORADOCONNECTICUTDELAWAREDISTRICT OF COLUMBIAFLORIDAGEORGIAHAWAIIIDAHOILLINOISINDIANAIOWAKANSASKENTUCKYLOUISIANAMAINEMARYLANDMASSACHUSETTSMICHIGANMINNESOTAMISSISSIPPIMISSOURIMONTANANEBRASKANEVADANEW HAMPSHIRENEW JERSEYNEW MEXICONEW YORKNORTH CAROLINANORTH DAKOTAOHIOOKLAHOMAOREGONPENNSYLVANIARHODE ISLANDSOUTH CAROLINASOUTH DAKOTATENNESSEETEXASUTAHVERMONTVIRGINIAWASHINGTONWEST VIRGINIAWISCONSINWYOMING ZIP code Description of operations: Please click here if your client or landlord requires specific language on the ACORD certificate. You understand and agree any language entered in the description of operations wording field does not alter or change any of the policy's terms and conditions. Description of operations wording - some clients ask for specific language to be added to the ACORD certificate to meet their requirements. If your client has requested this, please enter it here. If not, please leave this section blank. Please provide a description of the services you will perform for this client: Please include a description of leased property and estimated value. Please describe your relationship with the third party and why an Additional Insured status is being requested. ACORD REQUEST Certificate holder (the name of the business requesting a certificate of insurance) Street Secondary street (optional) City State: Please SelectALABAMAALASKAARIZONAARKANSASCALIFORNIACOLORADOCONNECTICUTDELAWAREDISTRICT OF COLUMBIAFLORIDAGEORGIAHAWAIIIDAHOILLINOISINDIANAIOWAKANSASKENTUCKYLOUISIANAMAINEMARYLANDMASSACHUSETTSMICHIGANMINNESOTAMISSISSIPPIMISSOURIMONTANANEBRASKANEVADANEW HAMPSHIRENEW JERSEYNEW MEXICONEW YORKNORTH CAROLINANORTH DAKOTAOHIOOKLAHOMAOREGONPENNSYLVANIARHODE ISLANDSOUTH CAROLINASOUTH DAKOTATENNESSEETEXASUTAHVERMONTVIRGINIAWASHINGTONWEST VIRGINIAWISCONSINWYOMING ZIP code Description of operations: Please click here if your client or landlord requires specific language on the ACORD certificate. You understand and agree any language entered in the description of operations wording field does not alter or change any of the policy's terms and conditions. Description of operations wording - some clients ask for specific language to be added to the ACORD certificate to meet their requirements. If your client has requested this, please enter it here. If not, please leave this section blank. ADD AUTHORIZED PERSON Authorized Person Name Authorized Person Last Name Role Phone Number Email Address ADDRESS CHANGE Street Secondary street (optional) City State: Please SelectALABAMAALASKAARIZONAARKANSASCALIFORNIACOLORADOCONNECTICUTDELAWAREDISTRICT OF COLUMBIAFLORIDAGEORGIAHAWAIIIDAHOILLINOISINDIANAIOWAKANSASKENTUCKYLOUISIANAMAINEMARYLANDMASSACHUSETTSMICHIGANMINNESOTAMISSISSIPPIMISSOURIMONTANANEBRASKANEVADANEW HAMPSHIRENEW JERSEYNEW MEXICONEW YORKNORTH CAROLINANORTH DAKOTAOHIOOKLAHOMAOREGONPENNSYLVANIARHODE ISLANDSOUTH CAROLINASOUTH DAKOTATENNESSEETEXASUTAHVERMONTVIRGINIAWASHINGTONWEST VIRGINIAWISCONSINWYOMING ZIP code Square feet occupied at this address Total number of business locations Any change in business services, if yes please describe. BUSINESS NAME CHANGE Reason for change Typographical Error Other, please explain Reason for change explanation Has your business experienced any of the following? Adverse financial event YesNo Unreported claim or loss YesNo Change in services YesNo Change in control YesNo Merger, acquisition, or other change in ownership YesNo Business Name POLICY DOCUMENT REQUEST Reason for Request Resend Policy purchase documents Other Please advise what document/documents are requested AGENT & PARTNER SERVICING REQUESTS Please select one or more of the following options Partner Agent ID Request a Loss Run Missing Credit for Policy Sale or Commission Request Broker or Agent of Record Change Submit Documents REQUEST A LOSS RUN Named Insured (Business Name) Hiscox Policy Number Where should we send the Loss Run Report (Email Address)? MISSING CREDIT FOR POLICY SALE OR COMMISSION Named Insured (Business Name) Hiscox Policy Number Date of Sale Any other additional comments REQUEST BROKER OR AGENT OF RECORD CHANGE Broker of Record Change Form Effective Date Please upload your completed request form. We will contact you if we need further information. Any other additional comments (optional) Uploaded documents You will receive a set of your most recent Hiscox policy documents via email within one business day. Hiscox Agent If applicable, please enter the name of the Hiscox Agent who requested these documents. Please describe briefly what you would like us to do with these submitted documents. If this is in response to a request from us, please provide a brief description regarding the reason we asked for these documents (as this request will be processed by a different individual than the one you spoke to or heard from earlier.) Please limit your response to 1000 characters Please click "Browse" and "Upload" to submit up to 5 files with a total size of 25 MB. Acceptable files: PDFs, Outlook email files (.msg), HTML files, Word docs, Excel docs and jpgs. Thanks for choosing Hiscox to protect your client’s business. Accessibility Terms of use Privacy policy Legal notices © 2022 Hiscox Inc. All rights reserved Underwritten by Hiscox Insurance Company Inc. Coverage is subject to underwriting and may not be available in all states. COOKIES INFORMATION When you visit our website, we store cookies on your browser to collect information. The information collected might relate to you, your preferences or your device, and is mostly used to make the site work as you expect it to and to provide a more personalized web experience. However, you can choose not to allow certain types of cookies, which may impact your experience of the site and the services we are able to offer. 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