Insurance Plus

214-351-4097 Texas

Home

Auto Insurance Homeowners Insurance Commercial Insurance

Privacy

Auto

  Online Quote Requests

  Auto Insurance Quotes

  SR-22 Insurance Quotes

  Home Insurance Quotes

  Professional Liability

  Rental Property

   

Some of the Companies We Represent

In Texas

American Hallmark

Affirmative Insurance

American Southwest Ins.

American Century Casualty

Safeway Insurance Select General

Bristol West of Texas

United Auto Insurance

Unitrin Insurance

Phoenix Insurance

Fred Loya Vision General

Infinity Insurance Group

Van Wagoner Insurance

Texas United Insurance

 

If you need assistance with this Online Form --->            Call Our phone 214-351-4097 


Agency of Record Transfer

and

Online Payment Request

You may use this form to Request that Your Policy be transferred to Insurance Plus from your existing Agency. and make your First Online Payment through our agency. Upon processing we will be your official Agent of record. Future servicing will then be handled by our Agency.

Please verify from the list below that we represent your Insurance Company before requesting a transfer to Our Agency. Only the First Named Insured on the Policy may complete this form,

 * Required Fields

 Policy Holder

Named Insured  * :

              Date:    

Address:  * :

      Apt # (If Any)

City:  * :

     State: *       Zip: *    

Phone: * :

         Email Address: *     
   

Type of Policy: * :

   

Insurance Co. * :

    Policy #: *   
   

 Change Request

Effective as of the date of this filing I hereby appoint Insurance Plus as my Exclusive Insurance Agent of Record for the referenced policy and permission is here granted to transfer any and all information and details for this Insurance policy to my new agent. 

 Payment Method

 Only fill this section if you need to make a payment at this time

Card Type & Card Number:

 Visa   MasterCard  Discover

Card Expiration Date:

( example: 08/03 )

Billing Zip Code: ( Zip of address at which

 you receive your card statement)

Security Code:

( 3 digit code on the back of your card )

Payment Amount:

    $          

 

 Signature Authority

Do you authorize your Typed entry below as your  Electronic Signature  

 

Signature          ( Type your name here )

 *   

  Submit Request

Submit Your Order

Please click on "Submit" to place your order for your Agent of record Change