Transcription of AGENT/BROKER OF RECORD CHANGE - ACORD …
1 DATE (MM/DD/YYYY) AGENT/BROKER OF RECORD CHANGEPOLICY NUMBER(S)EFFECTIVEDATEEXPIRATIONDATELINE OF BUSINESSNAMED INSURED(AS IT APPEARS ON POLICY)Please be advised that we wish to nameas our exclusive representative effectivefor the lines of business shown above, currently in force or submittedby #DATEINSURED'S SIGNATUREDATEThis authorization replaces any other authorization that may have beenpreviously completed for any other insurance representative for thestated lines of NAME (IF APPLICABLE)TITLE (IF APPLICABLE)STREET ADDRESS OF INSUREDCITY OF INSUREDZIP CODE OF INSUREDSTATE OF INSUREDINSURANCE COMPANY NAMECURRENT AGENCYCURRENT PRODUCERACORD 36 (2007/01)The ACORD name and logo are registered marks of ACORD ACORD CORPORATION 1996-2007.
2 All rights :E-MAILAGENCY CUSTOMER ID:CODE:SUBCODE:NEW AGENCYFAX(A/C, No):PHONE(A/C, No, Ext):ACORDs provided by Forms Boss. ; (c) Impressive Publishing 800-208-1977
