Broker of Record Procedure

If you wish to have our agency take over the servicing of an existing policy please copy and paste the letter below to your company letterhead. If individual policies, please enter your Name, Address, City, State and Zip. Please note to replace date and list insurance companies and policy numbers you wish to have us assume. Once completed and signed, mail or fax the form to us as indicated in our contact page.

(FOR BUSINESS PLACE THE LETTER ON YOUR LETTER HEAD
--OR--
FOR INDIVIDUALS PLEASE ENTER

NAME
ADDRESS
CITY, STATE. ZIP)

(DATE)

RE: Appointment of Smith, Bell & Thompson as our Agent/Broker of Record

To Whom it May Concern:

This will confirm that we have appointed Smith, Bell & Thompson as our exclusive insurance agent/broker of record for the following policies

1. (COMPANY) - Policy #:
2. (COMPANY) - Policy #:
3. (COMPANY) - Policy #:

The appointment of Smith, Bell & Thompson rescinds all previous appointments and the authority contained herein shall remain in force until canceled by us in writing.

This letter also constitutes your authority to furnish Smith, Bell & Thompson’s representative with all information they may request as it pertains to our insurance contracts, rates, reserves, retention, and all other financial data they may wish to obtain for their study of our present and future requirements in connection with our insurance policies.

Sincerely,

(NAME)
(COMPANY / INDIVIDUAL NAME)
(TITLE, IF APPLICABLE)