Insurance AOR Request Form

INSURANCE AOR REQUEST FORM

Applicant / Insured Information

Date of Birth:    Phone:    Email:

Individual Corporation LLC Trust Other

Policy Details

Policy Type:    Coverage Limit: $    Deductible: $

Policy Period From:    To:    Annual Premium: $

Scope: All current and future policies for the named insured Only policies listed above

Agent / Broker to be Appointed (Agent of Record)

Phone:    Email:

Authority Granted

By signing this form, Client Name: hereby appoints the Agent/Broker named above as Agent of Record with full authority to act on behalf of the insured as set forth below. This appointment authorizes the Agent to receive policy information, bind or endorse coverages on the insured's behalf where permitted, receive policy and claim correspondence, and to request and receive copies of policy and claim-related documents from the insurer and third-party administrators.

The Agent is authorized to: Receive policy documents, declarations, and endorsements Communicate with insurer regarding claims and loss information Request policy changes, endorsements and clerical updates Receive commission and compensation information Other (specify below)

Prior Agent / Revocation

This appointment supersedes and revokes any prior Agent of Record designation for the policies specified above, effective upon receipt by the insurer or administrator. Prior Agent Name (if known):

Exclusions and Limitations

The Agent of Record shall not be empowered to settle claims in the insured's name, execute instruments that alter ownership of insured property, or otherwise exercise any authority expressly prohibited by statute or by the insurer's rules. Specific exclusions or limitations (if any):

Beneficiary Designation (If Applicable)

For life or other applicable policies, beneficiary information may be provided here. Beneficiary Name:    Relationship:    Share %:

Documentation Checklist

Please indicate which documents are attached to support this appointment: Current policy declarations Signed authorization or power of attorney Agent acceptance letter Other supporting documents

Certification and Consent

I certify under penalty of perjury that the information provided on this Insurance AOR Request Form is true and correct to the best of my knowledge. I authorize the insurer, its agents, representatives and third-party administrators to release policy, claims and billing information to the Agent of Record named above for the purposes of policy administration, renewal, servicing and claims handling. This authorization shall remain in effect until revoked in writing by the undersigned.

I understand that this AOR Request may affect who receives commission payments and who is recognized by the insurer as the agent of record for servicing and marketing purposes. I agree to hold the insurer and its representatives harmless for acting on this instruction prior to receipt of any written revocation.

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