Transcription of AGENT/BROKER OF RECORD CHANGE
1 AGENCYCUSTOMER ID: AGENT/BROKER OF RECORD CHANGEP lease be advised that we wish to nameas our exclusive representative effectivefor the lines of business shown above, currently in force or submitted authorization replaces any other authorization that may have beenpreviously completed for any other insurance representative for the statedlines of (MM/DD/YYYY)INSURANCE COMPANY NAMECODE:SUBCODE:PRODUCERCODE #DATEINSURED'S SIGNATUREDATETITLE (IF APPLICABLE)COMPANY NAME (IF APPLICABLE)FAX(A/C, No):PHONE(A/C, No, Ext):ADDRESS:E-MAIL ACORD CORPORATION 1996-2007. All rights ACORD name and logo are registered marks of ACORDACORD 36 (2007/01)NEW AGENCYCURRENT PRODUCERCURRENT AGENCYPOLICY NUMBER(S)EFFECTIVEDATEEXPIRATIONDATELINE OF BUSINESSNAMED INSURED(AS IT APPEARS ON POLICY)ZIP CODE OF INSUREDSTATE OF INSUREDCITY OF INSUREDSTREET ADDRESS OF INSURED
