Insurance Broker of Record Authorization Form
Authorize a new insurance broker of record for your insurance policy using this Insurance Broker of Record Authorization Form.
Policyholder Full Name
*
First Name
Last Name
Policyholder Email Address
*
example@example.com
Policyholder Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Current Insurance Company Name
*
Insurance Policy Number
*
Effective Date of Authorization
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
New Broker/Agency Name
*
New Broker/Agency Contact Email
*
example@example.com
Additional Instructions or Notes (optional)
Signature of Policyholder (Authorizing this change)
*
Authorize Broker of Record
Authorize Broker of Record
Should be Empty: