Agent of Record Change Request
Date:
To whom it may concern:
I am hereby requesting that _____________________________________________________________________agency,
code _____________________, be assigned as my agent of record, effective ___________________________________,
for all current/future changes and service on my Farmers policies listed below:
Automobile Policy Number:
Homeowners Policy Number:
Personal Excess Liability Policy Number:
Boat Policy Number:
Other Number:
_______________________________________________________________
_______________________________________________________________
_______________________________________________________________
_______________________________________________________________
_______________________________________________________________
Thank you for your cooperation.
Insured's Name (print):
______________________________________________________________________________
Date
Signature
(mm/dd/yyyy)
Date
(mm/dd/yyyy)
Insured's Signature
Agent's Signature
Please email completed form to WARWICK COMMISSIONS at AgentChange@farmersinsurance.com.
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MPC-9735-000-0720
