Request for Equipment Change Insured Name Employee Completing Report/Title Email Phone Effective Date Type of Request ChangeAddDelete Year Make Model Serial Number Date Purchased NewUsed Storage Location Insured Value Additional Interest and/or Loss Payee Name and Address (if any) If non-owned, leased, or rented equipment, please indicate length of time equipment will be used and for what purpose. Length of Time Purpose Certificate of insurance required? YesNo Acknowledgement of this form will be your copy of our change request sent to the insured company. If you do not receive an acknowledgement within 5 days, please notify us. No coverage will be in effect until you receive confirmation from our office. If we have questions, please let us know the best way to reach you. Phone Number to Call Best Time to Call Submit OK -- Check if ready to send your info.