Transcription of AGENT/BROKER OF RECORD CHANGE DATE (MM/DD/YYYY) …
1 DATE (MM/DD/YYYY) AGENT/BROKER OF RECORD CHANGEPHONENEW AGENCYINSURANCE company NAME(A/C, No, Ext):FAX(A/C, No):E-MAILADDRESS:CURRENT AGENCYCURRENT PRODUCERCODE:SUBCODE:AGENCY CUSTOMER ID:NAMED INSUREDEFFECTIVEEXPIRATIONLINE OF BUSINESSPOLICY NUMBER(S)(AS IT APPEARS ON POLICY)DATEDATEP lease be advised that we wish to namePRODUCERas our exclusive representative effectiveCODE #DATEfor the lines of business shown above, currently in force or submittedby authorization replaces any other authorization that may have beenpreviously completed for any other insurance representative for thestated lines of 'S SIGNATUREDATETITLE (IF APPLICABLE) company NAME (IF APPLICABLE)STREET ADDRESS OF INSUREDCITY OF INSUREDSTATE OF INSUREDZIP CODE OF INSUREDACORD 36 (2007/01) ACORD CORPORATION 1996-2007.
2 All rights ACORD name and logo are registered marks of ACORD
