John Doe 123 Any Street Small Town, GA 000000

Address Here

To whom it may concern:

Please be advised that I wish to name, (Name of Agent), Agent for (Company name here) as my agent representative effective immediately for the policy:

_____________________________________shown above and currently in force. This form replaces any other authorization that may have been previously completed on an insurance representative for the stated line of business.

______________________________________ (Policyholder Signature )

______________________________ Date

______________________________________ Policyholder (PRINT NAME)

++++++++++++++++++++++++++++++++++++++++ As the new agent, I accept the assignment of the above named group/individual as their Agent of Record. I further certify that all the information shown above is correct and complete to the best of my knowledge. I also understand that commission will not be payable until the effective date of the Agent of Record change per established guidelines and the policy will not be visible in any online book of business until the effective date of the change.

_______________________________________ (Agent's Signature)

_________________________ Date

______________________________________ (Agent's Insurance Company ID Number)