Mid States Insurance, Inc.

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Change of Name

Form: Change of Name

Existing Policy: Change of Name

Contact Information

Your Full Name: (as listed on policy now)
Your Email Address:
Daytime Telephone Number:
Policy Number:

Change Request

Your FORMER Name:
Your NEW Name:
Reason for Name Change:
Additional Comments:
Questions:

By submitting this form you understand that no coverage is bound until you receive written notice. Changes to policies via this website are not effective or binding until you, or any party involved, receive official notification from your insurance agent, or your insurance company. If you have any questions, please feel free to contact us.

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