Agent/Broker Change - Authorization Form

Change of Agent/Broker Request
What is your first name? **
What is your first name? *
What is your last name? *
What is your last name? *
What is your email address? **
What is your email address? *
Is this change of agent form for your business or personal insurance policies? **
Is this change of agent form for your business or personal insurance policies? *
- Business
- Personal
What is your home address?
What is your home address?

Street Address Address Line 2 City State ZIP Code
What is your business address?
What is your business address?

Street Address Address Line 2 City State ZIP Code
Please select the insurance company with which your policy(s) is/are placed.
Please select the insurance company with which your policy(s) is/are placed.
Please enter the name of the insurance company with which your policy(s) is/are placed.
Please enter the name of the insurance company with which your policy(s) is/are placed.
How many policies do you want to transfer? **
How many policies do you want to transfer? *
Please enter a number from 1 to 7.
Please enter your policy information below. (Click the plus sign to enter additional more than one policy.)
Please enter your policy information below. (Click the plus sign to enter additional more than one policy.)
Named Insured (As it appears on policy) Policy Number Effective Date (MM/DD/YY) Expiration Date (MM/DD/YY) Line of Business
Signature - Sign your name to authorize this agent change. **
Signature - Sign your name to authorize this agent change. *
Enter the date you are signing this form. **
Enter the date you are signing this form. *
MM slash DD slash YYYY
Enter the date you would like this agent/broker of record change to take effect. **
Enter the date you would like this agent/broker of record change to take effect. *
MM slash DD slash YYYY
Enter your title, if applicable.
Enter your title, if applicable.
Enter your company name, if applicable.
Enter your company name, if applicable.
What is the name of your current agency/brokerage?
What is the name of your current agency/brokerage?
What is the name of the producer who currently handles your policies?
What is the name of the producer who currently handles your policies?
New Agency Information
This section is for the agent to complete.
Enter the date this form was generated.
Enter the date this form was generated.
MM slash DD slash YYYY
Please enter the name of the agency.
Please enter the name of the agency.
Please enter the agency's producer code.
Please enter the agency's producer code.
Please enter the producer's name.
Please enter the producer's name.
Please enter the agency's phone number.
Please enter the agency's phone number.
Please enter the agency's fax number.
Please enter the agency's fax number.
Please enter the agency's email address.
Please enter the agency's email address.
Enter the agency's customer ID, if applicable.
Enter the agency's customer ID, if applicable.
Please enter the agency's address.
Please enter the agency's address.

Street Address Address Line 2 City State ZIP Code
Documents and Comments
Please use this field to upload any relevant documents. (ie. Current policy declarations pages, etc...)
Please use this field to upload any relevant documents. (ie. Current policy declarations pages, etc...)
Drop files here or

Max. file size: 128 MB, Max. files: 10.
Please enter any additional remarks in the space below.
Please enter any additional remarks in the space below.
How did you hear about us?
How did you hear about us?
Please share who referred you to us.
Please share who referred you to us.
Can you share what you typed into Google?
Can you share what you typed into Google?
Please let us know how you heard about us.
Please let us know how you heard about us.
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Consent*
Disclaimer: This online questionnaire is a tool used to gather information. It is not an application for insurance. No insurance coverage will be bound or put into effect by submitting this form.

Consumer disclosure: By checking the box below you authorize the Agency who supplied this form to you to contact you via phone, email, and text messaging; to save and share with business partners the information you provided; to obtain consumer reports that may include credit-based reports (where legally allowed), public records, claims history, and driving records so that they can give you accurate insurance quotes.
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