Michigan Basic Property Insurance Association®
3245 E. Jefferson
Detroit, MI 48207
313-877-7400



Richard Robertson, General Manager
         
   
         
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Please complete the information requested below. Use the "Requested Changes" box to indicate those items that you wish to have performed to the policy. Please be sure  to supply us with your requested effective date for the change or cancellation. All requests must also indicate the reason for the change (i.e.; Property Sold, Replacement Cost Has Changed, Insured Has Moved, etc.). All fields must be completed. 

If there is any problem in processing your request, we will attempt to get back with you within two business days. 

Your Name:
  
 Company Name:
  
 Address 1:
  
 Address 2:
  
City:
  		 State/Province:
 		 Zip/Postal Code:
 
Country:
  		 Telephone:
 		 Fax:
  
Email:
  



Policy Number:                 

Claim Number (if any):      

My Interest in this Policy is that of:          

Named Insured:     

Property Address:  
City:
  		 State/Province:
 		 Zip/Postal Code:
 




 

 Requested Effective Date of Change/Cancellation:   

Requested Change(s):

   
 

 
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