Insurance AOR Transfer Request

INSURANCE AOR TRANSFER REQUEST

This Insurance Agent of Record (AOR) Transfer Request authorizes the insurer identified below to recognize the New Agent as the Agent of Record for the policy(ies) listed, and to release and transfer policy information, billing authority, and claim correspondence as specified herein. Completion of this form constitutes the Insured's written authorization and revocation of any previously executed AOR designations to the extent set forth in the Authorization and Revocation clause.

Applicant / Insured Information

Individual Corporation / Business Trust / Other

Policy Information

Policy Period Effective Date:   to  

Current Agent of Record

New Agent to Be Designated

Scope of Agent of Record Authority

The Insured authorizes the New Agent to act as Agent of Record for the following functions (select all that apply):

Billing and premium notices Policy servicing and endorsements Claims reporting and correspondence Cancellation and reinstatement communications Premium financing arrangements Other (describe below)

Coverage Types to Transfer

Select policy lines subject to this AOR transfer:

Property Casualty / General Liability Auto Life Health Professional Liability / E&O Other:

Exclusions and Limitations

The following items are expressly excluded from this AOR transfer unless separately initialed and acknowledged:

Policies currently subject to premium finance agreements without lender consent Active claims under dispute where claimant authorization is required Confidential attorney-client communications or privileged investigations Other exclusions (describe below)

Beneficiary Designation (if applicable)

Provide beneficiary information only for life or similar policies where beneficiary designations are maintained with the insurer.

Documentation Checklist

The following documents are provided with this request (attach copies where required):

Policy Declarations Page New Agent License / Agency Identification Prior AOR documentation (if any) Signed authorization (this form) Other supporting documents

Authorization and Revocation

By signing below, the Insured hereby authorizes the Insurer and the Current Agent to release policy information, premium and billing records, claims files, and other underwriting or loss information to the New Agent for the purpose of servicing, billing, claims handling, and other functions specifically selected in this form. This authorization includes the release of personally identifiable information necessary for servicing the policy(ies).

The Insured hereby revokes any prior Agent of Record designation to the extent necessary to effectuate this transfer, except where a separate, written agreement between the Insured and Current Agent provides otherwise. This transfer is subject to the insurer's records and any requirements of the original policy terms, including any finance or premium collection agreements.

Effective Date of Transfer:

The Insured acknowledges and agrees that the insurer may require acceptance of the New Agent before the New Agent is fully recognized for certain functions. The Insured further acknowledges that this AOR transfer does not relieve the Insured of any policy obligations, payments, or notice requirements, and that any dispute regarding commissions or compensation between agents is separate from this authorization and is not a matter for the insurer to resolve.

Certification

I certify under penalty of perjury that the information provided on this form is true and correct to the best of my knowledge. I authorize the insurer and my prior agent to release records as necessary to effectuate this Agent of Record transfer. I understand that false statements may subject me to penalties provided by law and by my insurance contract.

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