Policy Change Request 

CHANGE REQUEST ACKNOWLEDGEMENT AND AGREEMENT

This Change Request Acknowledgement and Agreement ("Agreement") is entered into between Kansas Preferred Insurance Group, located at 34102 Commerce Dr. Suite B, De Soto, KS 66018 ("Broker"), and the undersigned client ("Client"). Together, the "Parties" agree as follows:

1. Policy Details

The Client currently holds an insurance policy with the following details:

2. Requested Changes

The Client requests the following changes to their insurance policy:

3. Acknowledgment of Changes

The Client confirms that:

1. The above-mentioned changes are accurate.

2. They request the Broker to submit these changes to the insurance company for approval.

3. They will promptly notify the Broker of any updates or errors in the provided information.

4. Premium Adjustments

The Client acknowledges that:

1. The requested changes may result in an adjustment to the insurance premium.

2. The Client agrees to pay any applicable premium adjustments once the changes are approved.

5. Effective Date

The requested changes will take effect on the date specified below, subject to approval by the insurance company. Until approval is granted, the Client understands that coverage remains as specified in the current policy.

6. Required Information

The Client agrees to provide any additional documentation or information required to process this request.

7. Broker's Role

The Client acknowledges that:

1. Kansas Preferred Insurance Group acts solely as their broker by submitting this request to the insurance company.

2. The Broker does not underwrite, approve, or make coverage decisions.

3. The insurance company's decision to approve, deny, or modify the requested changes is final and outside the Broker's control.

8. Entire Agreement

This Agreement constitutes the entire understanding between the Parties regarding the requested changes. It supersedes (replaces) any prior or contemporaneous communications or agreements related to this matter.

9. Hold Harmless

The Client agrees to hold Kansas Preferred Insurance Group and its representatives harmless from any claims, damages, or liabilities arising from:

1. The requested changes to the insurance policy.

2. The insurance company’s decision to approve, deny, or modify the requested changes.

3. Any impacts on coverage, premiums, or policy terms resulting from these changes.