22-313 (7-2011)
Agent of Record Change
Today’s Date: ___/___/_____
New Agency Name and Agency Code #: ________________________________________________________________
________________________________________________________________________________
Prior Agency Name: __________________________________________________________________
________________________________________________________________________________
Please be advised that we wish to name ___________________________________
Producer
__________________ as our exclusive representative, effective ___/___/_____ for the line(s) of
Agency Code # Date
business shown above, and currently in force.
This authorization replaces any other authorization that may have been previously completed for any
other insurance representative for the stated line(s) of business.
IMPORTANT NOTICE: This Agent/Broker of Record Change form must be received by the Grange
Home Office prior to the renewal processing date for the insured’s policy(s). The agent submitting
this form must contact the Grange Home Office prior to submitting, to verify renewal processing time
frames for each policy affected. If the policy(s) affected by this change is canceled or is non-renewed
for any reason prior to this agent of record change processing, it is the responsibility of the insured to
contact the new agency to request the policy be rewritten to a new policy, if eligible.
_________________________________________________________ ___/___/______
Insured’s Signature Date
_________________________________________________________ ___/___/______
Spouse’s Signature (If Applicable) Date
Worldwide Insurance Network/Smart Choice
Worldwide Insurance Network/Smart Choice
click to sign
signature
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