Broker Of Record

Please print this page out and fax or email back to InSite Insurance Services.

Fax: 860-461-1404
Email: info@insiteins.com

Your Company Name
Your Company Address
Your Company Town, State Zip
Agent/Broker of Record

Date: ____________________________

To Whom It May Concern:

Effective immediately, I ask that you recognize InSite Insurance Services of 433 South Main Street Suite 107, West Hartford, CT 06110 as Agent/Broker of Record on the following policy(ies):

Policy Number:
__________________________________________
__________________________________________
__________________________________________
__________________________________________

Expiration Date:
__________________________________________
__________________________________________
__________________________________________
__________________________________________

This appointment of agent rescinds all previous appointments and the authority contained herein shall remain in full force until cancelled in writing.

Please call if you have any questions regarding this authorization.

Thank you for your cooperation and assistance.

Regards,

Signature:
__________________________________________

Print Name:
__________________________________________