Get Agent/broker Of Record Change

Filling out the Agent/Broker of Record Change form is an essential step in updating your insurance representation. This guide will provide clear instructions to help you complete the form accurately and efficiently.

Follow the steps to successfully complete the form

1. Click the ‘Get Form’ button to obtain the form and open it in the editor.
2. Begin by entering the date in the format MM/DD/YYYY at the top of the form. This indicates when the changes will take effect.
3. Fill in the new agency's name and contact information, including the phone number and fax number. Ensure all details are accurate for future correspondence.
4. Next, state the insurance company name to which the agent or broker is connected. This section helps clarify the relationship between your agency and the insurance provider.
5. Enter the email address of the new agency for communication purposes. This should be monitored regularly for updates.
6. Provide the current agency and producer's details, including their agency customer ID for reference.
7. List the named insured as it appears on the policy. Ensure accuracy to avoid any complications later.
8. Include the policy number(s) for which you are changing the agent or broker. This helps in identifying the specific policies affected by this change.
9. Next, enter the effective date and expiration date of the new appointment. This specifies when the new broker will have the authority.
10. Indicate the line of business relevant to this change, ensuring that you are defining the category of insurance.
11. In the authorization section, name the producer you wish to designate as your exclusive representative. Include the code number that corresponds to this change.
12. Sign and date the document in the 'Insured's signature' section. If applicable, include your title and company name.
13. Finally, enter your street address, city, state, and zip code to complete the form.
14. After filling out all the necessary fields, review your entries for accuracy. Then save changes, download, print, or share the form as needed.

Complete your digitized documents online today to ensure a smooth transition in your insurance representation.