Important Message: Please remember the "Three Point Contact Rule" when getting on or off of vehicles and equipment.

Make Changes to Your Coverage

TOIRMA Account Change Form

Township/County

Date

Contact Name

Title

Phone

Auto

Add/Delete/Change

Department

Year

Make

Model/Type

Serial #

Value

Effective Date

Remarks

Property

Add/Delete/Change

Department

Name of Building

Address/Zip Code

Building Value

Type of Coverage for Building

Type Construction

Year Built

Contents Value

Type of Coverage for Contents

Effective Date

Remarks

Inland Marine

Add/Delete/Change

Department

Year

Make

Item

Serial #

Value

Type of Coverage

Effective Date

Remarks