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.
Are you a member of any associations?*

YesNo
Association name*
What would you like to do today?*

Change of addressChange of nameChange of activity/therapyIncrease in indemnity limit from £4m to £6mRequest duplicate schedule of insurance

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*

MarriageDivorceDeed PollOther
Please confirm the reason for requesting a duplicate schedule of insurance*

Lost/damaged originalNeed to show scheduleOther
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
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:

Personal AccidentBusiness ContentsAll Risks
Should be Empty: