Agent of Record Letter


Re:    Name Insured_________________________________________________________

Type of Policy_________________________________________________________

Insurance Company____________________________________________________

Policy Number_________________________________________________________

Day Phone_________________________Night Phone_________________________

Best Time To Call_______________ (   )am   (   )pm

Dear Underwriter:

Effective _________________________ I appoint Hall & Clark Insurance Agency 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 cancelled in writing.

Reason(s) for Agent Change:
____ Customer Moved
____ Agent Moved
____ Long Dist and/or Conv
____ One agent for all policies
____ Suggested by Agent
____ Suggested by Agent of Record
  ____ Discourteous Agent/Agency
____ Unsatisfactory Service
____ Personal Preference
____ Agent retired or left Company
____ Suggested by Management
____ Other (Please explain in remarks)



(Print Name)

(Title, if applicable)