Agent of Record Form

Date

Re:

Name Insured

Type of Policy

Insurance Company

Policy #

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 Dist and/or Convenience
Suggested by Management
Discourteous Agent/Agency
Unsatisfactory Service
Agent retired or left Company
Personal Preference
Other (Please explain in remarks)

Comments

_____________________________________________________________
(signature)

Print Name

Title (if applicable)

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