Murray-Jackson Insurance Brokers

MJ logo Existing clients of Murray Jackson Insurance Brokers can use this page to request a change of address, add/delete vehicles, change to monthly pay plan, change deductibles, review coverage, or information on a recently received renewal. All information is kept strictly confidential. For more detailed information, please see our Privacy Statement.

NOTE: 1) Murray Jackson Insurance Brokers does not provide facilities for credit card payment. 2) Submission of this form does not bind or confirm coverage. We will contact you upon receiving your request to confirm receipt and institute any required changes.

Mandatory fields are indicated with a red asterisk.

General Information…………………………………………………………………………


First Name:
Last Name:
Policy Number (required for security reasons):
Phone Number:
Email Address:
Preferred Method of Contact:	Email Telephone
Request Details………………………………………………………………………………
Effective date of change (MM/DD/YYYY):	CANNOT BACK DATE
Reason for Request:
If you would like to direct the request to a specific employee, enter their name:
Add Coverage Remove Coverage Add Driver Remove Driver
Request Details:
Upload Documents ( ie. Drivers training certificate, Student Card, Bill of Sale/Lease Agreement *(required on all 2009/2010 vehicles): Only doc/docx, pdf, txt, and rtf files are allowed!
Disclaimer and Privacy: DISCLAIMER: By submitting this request, it is hereby understood that this is not a Policy of Insurance, Insurance Application or Offer by Murray Jackson Insurance Brokers to insure on behalf of any Company. We reserve the right to accept or deny any and all requests, upon examination and analysis. All submitted change requests are not bound, covered or insured until you have been advised / contacted by one of our representatives in the preferred method of contact you have selected. If you require faster response, it may be better served to contact our office by phone during regular business hours (Monday to Friday).
By checking this box, I indicate that I have read, understood, and AGREE to the terms of Murray Jackson’s Privacy Statement.