Date_______________________
| 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) |
Remarks:__________________________________________________________________
(Signature)
_______________________________________________
_______________________________________________ |