Broker of Record Form

A document that lets a policyholder formally authorize a new broker to take over management of their insurance policy.

Use this template

Insurance Company Name

New Agent Name

Broker of Record Authorization Statement

Insured Name

Nombre

Apellido

Insured Address

Dirección

Ciudad

Estado / Provincia

Código postal

Policy Number

Email

Phone Number

Insured's Signature

Sign here

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