AGENCY
CUSTOMER ID:
AGENT/BROKER OF RECORD CHANGE
Please be advised that we wish to name
as our exclusive representative effective
for the lines of business shown above, currently in force or submitted by
application.
This authorization replaces any other authorization that may have been
previously completed for any other insurance representative for the stated
lines of business.
DATE (MM/DD/YYYY)
INSURANCE COMPANY NAME
CODE:
SUBCODE:
PRODUCER
CODE # DATE
INSURED'S SIGNATURE
DATE
TITLE (IF APPLICABLE)
COMPANY NAME (IF APPLICABLE)
FAX
(A/C, No):
PHONE
(A/C, No, Ext):
ADDRESS:
E-MAIL
© ACORD CORPORATION 1996-2007. All rights reserved.
The ACORD name and logo are registered marks of ACORD
ACORD 36 (2007/01)
NEW AGENCY
CURRENT PRODUCER
CURRENT AGENCY
POLICY NUMBER(S)
EFFECTIVE
DATE
EXPIRATION
DATE
LINE OF BUSINESS
NAMED INSURED
(AS IT APPEARS ON POLICY)
ZIP CODE OF INSURED
STATE OF INSURED
CITY OF INSURED
STREET ADDRESS OF INSURED
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