2208 Plaza Drive, Suite 115
Rocklin, CA 95765

938 S. Main Street
Pleasant Grove, UT 84062
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Broker of Record Procedure

If 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 and 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.


(FOR BUSINESS PLACE THE LETTER ON YOUR LETTER HEAD
--OR--
FOR INDIVIDUALS PLEASE ENTER

NAME
ADDRESS
CITY, STATE. ZIP)

(DATE)

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

1. (COMPANY) - Policy #:
2. (COMPANY) - Policy #:
3. (COMPANY) - Policy #:

The 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.

Sincerely,



(NAME)
(COMPANY / INDIVIDUAL NAME)
(TITLE, IF APPLICABLE)

 

Phone: (916) 380-5952 · Fax: (916) 380-5953 · Toll Free: (888) 760-9292 · Mon-Thu 8:30a-5p · Fri 8:30a-4p · closed Sat, Sun, major holidays
 AGENCY LICENSE CA OH31779  OR 821996  NV 752542  UT 376404
© 2018 Neilson & Phillips Insurance Services, Inc., All Rights Reserved 
Disclaimer - Informational statements regarding insurance coverage are for general description purposes only. These statements do not amend, modify or supplement any insurance policy. Consult the actual policy or your agent for details regarding terms, conditions, coverage, exclusions, products, services and programs which may be available to you.