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AGENT OF RECORD FORM

AGENT OF RECORD REQUEST

If you would like to appoint our agency as your exclusive agent of record, please fill out and submit the form below. After receiving your submission you will be contacted shortly by one of our qualified agents.
 

Date:

Re:
Insured First Name:
 
Insured Last Name:
 
Type of Policy:
 
Insurance Company:
 
Policy Number:
 
Day Phone:
Night Phone:
 
Best Time To Call:
AM PM


Dear Underwriter:


Effective I appoint as my exclusive agent of record for the captioned policy and permission is granted to develop underwriting information for our insurance account.

This appointment rescinds all previous appointments and the authority granted will remain in force until cancelled in writing.


Reason(s) for Agent Change:

Agent Moved
Customer Moved
One agent for all policies
Suggested by Agent
Suggested by Agent of Record
Long Dist and/or Convenience 		  Suggested by Management
Discourteous Agent/Agency
Unsatisfactory Service
Agent retired or left Company
Personal Preference
Other (Please explain in remarks)

Comments:
_______________________________________________
(Signature)


(Print Name)


(Title, if applicable)


(Email,required)




17821 E 17th St, Suite 100, Tustin, CA 92780 :: LICENSE #0543173