Read Acord%2036.pdf text version

Clck here to Clear Fields

Click here to Send Form

AGENT/BROKER OF RECORD CHANGE

AGENCY PHONE (A/C, No, Ext): FAX (A/C, No): INSURANCE COMPANY NAME

DATE (MM/DD/YYYY)

E-MAIL ADDRESS: CODE: AGENCY CUSTOMER ID: SUBCODE:

POLICY NUMBER(S)

EFFECTIVE DATE

EXPIRATION DATE

LINE OF BUSINESS

ggggg ggg ggg ggg ggg gg gg

gg gg gg gg gg ggg gg

Please be advised that we wish to name

CODE #

PRODUCER DATE

as our exclusive representative effective

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 SIGNATURE

DATE

TITLE (IF APPLICABLE)

COMPANY NAME (IF APPLICABLE)

ACORD 36 (2006/08)

© ACORD CORPORATION 1996-2006. All rights reserved. The ACORD name and logo are registered marks of ACORD

Information

1 pages

Report File (DMCA)

Our content is added by our users. We aim to remove reported files within 1 working day. Please use this link to notify us:

Report this file as copyright or inappropriate

8590


You might also be interested in

BETA
Acord form:
Microsoft Word - ProducerGuide-Redwood04.23.doc