Balens Mid-Term Amendment Form

Your Name

First NameLast Name
Your email address
example@example.com
Your postcode
Your phone number
Please enter a valid phone number.Format: 00000-000000.
Are you a member of any associations?
Association name
What would you like to do today?

Please confirm your NEW address below:
Address

Address line 1

Address line 2

Town/CityCounty

Postcode
Please confirm your change of name

First NameLast Name
N.B. Your policy must be in your legal name.
Please confirm the reason for the change

Other
Please confirm the reason for requesting a duplicate schedule of insurance

Other
Please insert the activity/therapy you are looking to add
If you would like to add more than one activity/therapy, please separate them using a comma.
Please note: No cover will be in place for the activity described above until you receive confirmation from Balens that it has been added to your policy.
If adding this additional activity results in an additional premium being due, we will contact you with a quotation and payment details.
Please note: Any indemnity increase will not be in place until you receive confirmation from Balens that it has been added to your policy, and if this increase results in an additional premium being due, we will contact you with a quotation and payment details.
Please confirm the effective date

DayMonthYear
Date
Consequences of Dishonesty (Non-Disclosure/Misrepresentation)

If you lie or fail to disclose relevant information or are not being honest can result in the voiding of your policy, the rejection of claims, and difficulty obtaining insurance in the future.
If you would like to add the following cover to your policy, please select and one of our team will contact you to discuss this further:
Should be Empty: