Change of Address Form

Disclaimer: I understand that my coverage or changes in coverage ARE NOT binding via this on-line request. Changes ARE considered binding when I receive an email or fax response from Long Insurance Group indicating that the changes have been made.

 I have read and agree with the above disclaimer.
* (Box must be checked before request can be sent)

POLICY INFORMATION:

POLICY HOLDER INFORMATION

OLD ADDRESS:

NEW ADDRESS:

* Required field