By submitting this policy change request, I declare that I am a duly authorized representative and/or signatory of the entity specified above and possess the requisite authority to effectuate modifications to the insurance policies procured through Fairbanks Insurance Brokers Inc.
 
Important Note: This submission does not automatically modify coverage. The original terms and conditions of the policy will remain unchanged until the carrier has reviewed, approved, and issued a formal endorsement. We strongly advise that you only assume modifications are in effect once official documents are received.