Please fill out the following form to change or add a mortgagee to an existing home policy. We will fax an Evidence of Property Insurance showing the bank as mortgagee as soon as possible after receiving the information. If you have any questions, please contact us at 231-347-8113 or send email to insurance@harborbrenn.com.

Insured's Name: *

Policy Number:

Location Address:

Mortgagee Name: *

Address: *

Position: * First MortgageeSecond MortgageeThird Mortgagee

Action:

Replaceing existing?

Adding New?

Purpose of Loan:

Refinance?

Renovating?

New Construction?

Effective date:

JanFebMarAprMayJunJulAugSepOctNovDec

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Account/Loan #:

Escrow:

Yes

No

Fax #:

(we will fax evidence of property insurance as soon as possible)

Contact name: *

(for questions)

Contact Phone #: *

Any additional information needed?:

Comments:

By checking this box, you are acknowledging you have a signed Authorization to Disclose Information form from the insured allowing you to receive this information. If you do not have this form, we will need to contact the insured for permission to release this information. This could delay processing time of your request.