Broker of Record Procedure
you wish to have our agency take over the servicing of an existing
policy please copy and paste the letter below
to your company letterhead. If individual policies, please enter
your Name, Address, City, State and Zip. Please note to replace date
list insurance companies and policy numbers you wish to have us assume.
Once completed and signed, mail or fax the form to us as indicated
in our contact page.
BUSINESS PLACE THE LETTER ON YOUR LETTER HEAD
FOR INDIVIDUALS PLEASE ENTER
CITY, STATE. ZIP)
RE: Appointment of Neilson & Phillips Insurance Services, Inc. as our Agent/Broker of Record
To Whom it May Concern:
This will confirm that we have appointed Neilson & Phillips Insurance Services, Inc. as our exclusive
insurance agent/broker of record for the following policies
(COMPANY) - Policy #:
2. (COMPANY) - Policy #:
3. (COMPANY) - Policy #:
appointment of Neilson & Phillips Insurance Services, Inc. rescinds all previous appointments
and the authority contained herein shall remain in force until
canceled by us in writing.
This letter also constitutes your authority to furnish Neilson & Phillips Insurance Services, Inc.’s
representative with all information they may request as it pertains to our
insurance contracts, rates, reserves, retention, and all other financial data
they may wish to obtain for their study of our present and future requirements
in connection with our insurance policies.
(COMPANY / INDIVIDUAL NAME)
(TITLE, IF APPLICABLE)