Who must sign the form?

The insured (or authorized representative) and the incoming broker typically must sign. Some carriers also request an outgoing broker signature or release; check carrier-specific requirements before submission.

Can the form be signed electronically?

Yes. Electronic signatures are valid under ESIGN and UETA for most commercial transactions. Confirm carrier acceptance and retain a verifiable audit trail showing signer attribution and intent.

Is notarization required?

Not usually required by all carriers, but some states or carriers may request notarization or witness signatures. Verify the carrier's template instructions and state notary rules before submitting.

What if names don't match policy records?

Provide supporting documentation such as DBA statements or corporate resolution. Name mismatches frequently cause verification delays and may require corrective documentation.

How long does processing take?

Carrier acknowledgement commonly takes 3–10 business days, but timing depends on carrier workload and whether additional documents are requested.

What evidence should I keep?

Retain the signed form, any carrier acknowledgment, and the complete eSignature audit trail (timestamps, IP, and signer authentication) for the recommended retention periods.

Electronic Signature
Templates
Insurance
Insurance BOR Change Form

Insurance BOR Change Form

This template is fully customizable. Edit the text, fill out the fields, and send it for signature. Give it a try!

INSURANCE BROKER OF RECORD (BOR) CHANGE FORM

1. Applicant / Insured Information

Insured / Named Entity: Mailing Address:

Policy Number:

Date of Birth / Org. DOB:

Primary Contact Phone:

Primary Contact Email:

2. Policy Details

Insurer / Carrier:

Policy Type (select all that apply):

Commercial Property General Liability Professional Liability Auto Workers' Compensation Life / Health Other:

Coverage Limit(s):

Deductible:

Annual Premium:

Policy Period Start:

Policy Period End:

3. Current Broker of Record

Broker / Agency Name:

License / NPN:

Phone:

Broker Address:

4. New Broker of Record (Designation)

Designated Broker / Agency Name:

License / NPN:

Phone:

Broker Address:

By signing this form, the Insured authorizes the insurer, managing general agent, and administrator to designate the above named broker/agency as Broker of Record for the policies identified. This authorization includes the release of policy data, premium information, claims history, and other underwriting information necessary for the broker to service the account.

5. Effective Date of Broker Appointment / Revocation

I hereby revoke any prior Broker of Record designation for the policies listed above and appoint the new Broker of Record effective: Immediate or Effective Date:

If Immediate is selected, the insurer is authorized to update records to reflect the new Broker of Record upon receipt of this executed form. Requesting a specific Effective Date does not guarantee acceptance by the carrier; carrier acceptance is subject to carrier procedures and underwriting rules.

6. Coverage & Instructions to Carrier

Please indicate specific coverage lines or endorsements for which the Broker of Record designation applies (check all that apply):

Property General Liability Auto Workers' Compensation Professional Liability Other

Additional Instructions to Carrier:

7. Limitations, Exclusions and Acknowledgements

This Broker of Record change is an administrative designation for the purpose of broker representation and communication. It does not amend, alter, increase, or decrease coverage under any insurance policy. No broker appointment shall be construed to bind coverage or change policy terms without express written endorsement by the insurer. The carrier retains sole authority to accept or reject this Broker of Record change pursuant to its internal procedures.

The Insured understands and agrees that submission of this form authorizes the insurer to communicate policy information to the new broker and to accept instructions from the new broker regarding routine policy servicing unless otherwise restricted in writing by the Insured.

8. Beneficiary Information (If Applicable to Policy)

(Complete only if the policy type includes beneficiary designations such as Life or Health)

Beneficiary Name:

Relationship:

Share Percentage:

9. Certification / Authorization

I certify that I am authorized to act on behalf of the Insured named in this form. I warrant that the information provided is true and correct to the best of my knowledge. I authorize the insurer, its representatives, and the current broker to release policy information, including claims and loss history, to the designated Broker of Record. I understand that any misrepresentation or willful omission may affect the processing of this request and may result in denial of the Broker of Record change.

I hereby release and hold harmless the insurer, current broker, and designated broker from any liability arising solely from the administrative processing of this Broker of Record change, provided such processing is performed in good faith and in accordance with carrier procedures.

Signature of Authorized Applicant

Printed Name:

Title / Relationship:

Signature:

Date:

What the Insurance BOR Change Form Is

The Insurance BOR Change Form (Broker of Record Change Form) is a written authorization that transfers the right to represent an insured party from one insurance broker or agent to another. It records the insured, policy numbers, effective date, and the broker relationships and is submitted to the insurer or carrier for acknowledgement. The form creates the administrative record used to route policy communications, commission payments, and service requests; carriers typically require carrier-specific wording and may apply internal processing windows before the change takes effect.

Why a Clear BOR Change Form Matters

A properly completed Insurance BOR Change Form ensures accurate commission routing, prevents service interruptions, and documents consent for the carrier to accept a new broker. It reduces administrative delay and provides a clear audit trail for compliance and dispute resolution.

Who Completes and Signs This Form

Each signer should confirm identity, authority, and effective date to avoid processing delays and commission disputes.

Named insureds or policy owners who authorize a change of broker and confirm coverage details to the carrier.
Outgoing brokers who provide signatures or release statements when contractually required by agency agreements.
Incoming brokers or agents who accept appointment, supply license details, and request carrier acknowledgment.

Typical Signatories and Their Roles

Policyholder — Owner

The named insured or authorized representative signs to transfer broker authority; they must confirm policy numbers and consent to the new broker. Incorrect names or missing authorization can cause rejected requests and potential lapse in broker communications.

Broker — Incoming

The replacing broker signs to accept the appointment and provides license and contact information. This signature creates the carrier relationship for servicing and commission allocation and should match the broker's official agency name on licensing records.

Essential Fields to Include

Policy Number: Exact policy ID

Named Insured: Full legal name

Incoming Broker: Agency name and license

Outgoing Broker: Agency name and license

Effective Date: MM/DD/YYYY format

Signatures: Printed name and date

Consequences of Incorrect or Missing Information

Coverage Gap: Claims mishandled

Commission Dispute: Payment delays

Request Rejection: Carrier refusal

Regulatory Risk: License compliance issues

Data Mismatch: Record reconciliation

Fraud Exposure: Unauthorized changes

Common Preparation Pitfalls to Avoid

Using abbreviated or inconsistent insured names across documents, which leads to carrier rejection or manual reconciliation delays.
Failing to include broker license numbers or agency tax IDs, creating ambiguity for commission routing and regulatory reporting.
Overlooking carrier-specific instructions or required attachments, such as prior broker release letters or signed agency agreements.
Submitting forms without a clear effective date or with backdated signatures, which can trigger disputes over claim handling and commission entitlements.

How Organizations Use a BOR Change Form

Two practical examples show typical usage and operational impact across broker and carrier workflows.

Independent Agency Transition

A mid-size employer switched brokers to consolidate renewals and lower administration.

The incoming broker submitted a completed BOR form with license and W-9.
Carrier acknowledged within five business days; commissions were rerouted and historical servicing notes were transferred to the new agency to ensure continuity for renewals and claims handling.

Wholesale Broker Assignment

A wholesale broker reassigned client representation after acquisition of a retail firm.

Both brokers signed a release and the insured confirmed consent.
The carrier required a carrier-specific BOR template plus a signed agency contract; after verification, the carrier updated billing and appointed the incoming broker for commission disbursements.

Step-by-Step: Complete a BOR Change Form

Follow these four steps to prepare, verify, and submit a Broker of Record Change to an insurance carrier.

01

Prepare Details: Collect insured name, policy number, broker IDs, and W-9 if required.
02

Confirm Authority: Ensure the signer has signatory authority for the insured entity.
03

Sign and Date: All parties sign and include the effective date in MM/DD/YYYY format.
04

Submit to Carrier: Send to carrier compliance or producer services per carrier instructions.

Typical Processing Flow at the Carrier

Carriers follow a short verification and update cycle once a BOR Change Form is received.

Intake: Carrier receives the form via email, portal, or mail.
Verification: Carrier checks signatures, license numbers, and insured identity.
Update Records: Producer appointment and commission routing are updated in policy systems.
Acknowledgment: Carrier issues confirmation to insured and both brokers.

What a Professional BOR Change Form Should Include

A complete form reduces back-and-forth with carriers and speeds processing. Include clear identification, authority statements, and carrier-specific fields.

Identification

Full legal name of the insured and policy numbers so the carrier can unambiguously match the change to existing records; include DBA names where applicable to avoid mismatches.

Broker Data

Agency legal name, broker license number, NPN or agency tax ID, phone and email for both outgoing and incoming brokers to support appointment and commission setup.

Authority Statement

A short declaration signed by the insured authorizing the broker change, specifying whether the change affects claims handling or billing communications.

Effective Date

Clearly state the date when the new broker should begin receiving communications and commissions; use MM/DD/YYYY for consistency.

Carrier Fields

Carrier-specific checkboxes or attachments for agency agreements, prior broker release letters, or producer appointment forms that some carriers require.

Signature Block

Printed name, title, date, and a signature line for each party; include a contact phone number to resolve verification questions quickly.

Digital Workflow Settings to Use for Online Submission

Recommended digital settings help maintain identity, create an audit trail, and speed carrier acceptance when e-signing the BOR Change Form.

Field	Configuration
Signer Authentication	Email plus SMS code for basic verification
Signature Type	Typed name with recorded timestamp and IP
Attachment Requirement	Allow PDF upload for agency agreements
Audit Trail	Capture IP, timestamp, and action history

Technical Requirements for eSubmission and Storage

Ensure the chosen platform complies with ESIGN/UETA and can produce a reproducible audit trail suitable for carrier records and audits.

File Formats: PDF, DOCX accepted
Integrations: CRM and storage systems
Authentication: Email, SMS, or KBA

Timing Expectations and Carrier Processing Windows

Processing timelines vary by insurer; know typical carrier deadlines to set expectations for effective dates and commission shifts.

Requested Effective Date:

Specify MM/DD/YYYY. Carriers may honor or defer based on internal cutoffs.

Carrier Acknowledgment:

Typically 3–10 business days for validation and appointment.

Commission Adjustment:

May apply prospectively or retroactively per carrier rules and producer agreements.

Cancellation Notices:

Respect any insurer-required notice periods to avoid interruptions.

Record Retention:

Keep the executed form and audit trail per regulatory requirements.

Key Milestones from Request to Acknowledgment

A typical milestone sequence clarifies who must act and when to avoid processing delays.

01

Form Submission

Insured and incoming broker send completed form to the carrier.

02

Carrier Verification

Carrier validates identities, license numbers, and signatures.

03

System Update

Carrier updates producer appointment and commission routing.

04

Confirmation Issued

Carrier sends written acknowledgment to insured and both brokers.

How a BOR Change Differs from Similar Documents

Compare the Broker of Record Change Form with related documents to pick the correct tool for the situation.

Criteria	BOR Change	Assignment of Benefits
Purpose	change broker representation	assign claim payments
Signed By	insured + brokers	insured or claimant
Effect	changes servicing and commissions	directs claim proceeds
Carrier Process	administrative appointment update	claim-specific approval

eSignature Provider Comparison for Filing BOR Change Forms

Common plan and feature criteria for eSignature providers used to complete and submit BOR Change Forms. Pricing shown by vendor and plan starters where available.

	signNow	DocuSign	Adobe Sign	PandaDoc	HelloSign
Starting Price	$8/user/mo	$15/user/mo	$14/user/mo	$19/user/mo	$15/user/mo
Free Trial	7-day free trial	Varies by vendor	Varies by vendor	Varies by vendor	Varies by vendor
Bulk Send	Yes (Business Premium)	Varies by plan	Varies by plan	Varies by plan	Varies by plan
Audit Trail	Yes	Yes	Yes	Yes	Yes
HIPAA Compliant	Yes (BAA available)	Varies by plan	Varies by plan	Varies by plan	Varies by plan
Envelope Cap	No cap	100 envelopes/user/year	Varies	Varies	Varies

Frequently Asked Questions About the BOR Change Form

Answers to common questions about authority, signatures, eSubmission, and what carriers typically require.

Need help? Contact support

Who must sign the form?
The insured (or authorized representative) and the incoming broker typically must sign. Some carriers also request an outgoing broker signature or release; check carrier-specific requirements before submission.
Can the form be signed electronically?
Yes. Electronic signatures are valid under ESIGN and UETA for most commercial transactions. Confirm carrier acceptance and retain a verifiable audit trail showing signer attribution and intent.
Is notarization required?
Not usually required by all carriers, but some states or carriers may request notarization or witness signatures. Verify the carrier's template instructions and state notary rules before submitting.
What if names don't match policy records?
Provide supporting documentation such as DBA statements or corporate resolution. Name mismatches frequently cause verification delays and may require corrective documentation.
How long does processing take?
Carrier acknowledgement commonly takes 3–10 business days, but timing depends on carrier workload and whether additional documents are requested.
What evidence should I keep?
Retain the signed form, any carrier acknowledgment, and the complete eSignature audit trail (timestamps, IP, and signer authentication) for the recommended retention periods.

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