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For customers, please complete the appropriate form below. Please note that submitting a change request does not bind coverage. Incomplete information may cause a delay in processing your request. Upon receipt of your request, we will contact you.

By clicking "Submit", you agree to provide Select Church Insurance Services with the submitted information about you and / or your organization, that you are authorized agent and / or representative of the organization, that you have the authority to submit this request, and that the information provided is accurate.

Ministry Name Ministry City 
Policy Number (Last 6 Numbers)
Date to start coverage
New Location AddressStreet Address City State Zip Code County Inside City Limits
Primary Use
Building InformationMiles to Fire DepartmentDistance to Fire Hydrant
Briefly describe how you use this location including any special activities

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