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Get Agent Of Record Form Fillable

CUSTOMER ID: NAMED INSURED (AS IT APPEARS ON POLICY) POLICY NUMBER(S) EFFECTIVE DATE EXPIRATION DATE LINE OF BUSINESS Please be advised that we wish to name PRODUCER as our exclusive representative effective CODE # DATE 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. INSURED'S SIGNATUR.

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