Broker Of Record Form

Broker Of Record Form
Insurance company name
New agent name
1. Be advised that {insuranceCompany} would like to recognize {newAgent} as our Broker of record.
2. This letter rescinds all previous appointments and authority contained here in will remain in force until cancelled by us in writing.
3. This letter also constitues your authority to furnish our new representative with all information they may request as it pertains to our insurance contracts, rates, rating, schedules, services, reserves, retention and all other financial data they may wish to obtain for their study of our present and future requirements.
4. This recognition as our broker entitles them to any and all compensation paid by your company in conjunction with the placement, installation, and servicing of our insurance.
Insured name
First NameLast Name
Insured address
Street Address
Street Address Line 2
CityState / Province
Postal / Zip Code
Policy number
Email
example@example.com
Phone Number
Please enter a valid phone number.
Insured's signature
Clear
Should be Empty: