Agent of Record Form

If you would like to appoint our agency as your exclusive agent of record, please fill out and submit the form below. After receiving your submission you will be contacted shortly by one of our qualified agents.

All fields with an (*) are required

General Information

Date *

Name Insured *

Email Address *

Type of Policy *

Insurance Company *

Policy Number *

Daytime Phone *

Nighttime Phone *

Best Time to Call (AM/PM)? *

Dear Underwriter:

Effective , I appoint Southern California Insurance Brokerage, Inc. as my exclusive agent of record for the captioned policy and permission is granted to develop underwriting information for our insurance account.

This appointment rescinds all previous appointments and the authority granted will remain in force until canceled in writing.

Reason(s) For Agent Change?

Agent Moved

Customer Moved

One Agent for all Policies

Suggested by Agent

Suggested by Agent of Record

Long Distance and/or Convenience

Suggested by Management

Discourteous Agent/Agency

Unsatisfactory Service

Agent Retired or Left Company

Personal Preference

Other (Please explain in comment)

Comments *

Please type the two words in the image in the text box below. * Unfortunately, this is necessary to prevent automated form submissions. Thank you for your cooperation.

Stay Informed with the Latest News

Southern California Insurance Brokerage's knowledgeable staff has consistently provided friendly, efficient and timely customer service for all our specific insurance needs...
-John Ericson