Insurance Broker Consent Form

INSURANCE BROKER CONSENT FORM

Client Name:

Applicant / Insured Information

Date of Birth:

Policy Details

Coverage Limit:    Deductible:    Annual Premium:

Policy Period From:    To:

Coverage Selection

Select the coverages the Broker is authorized to quote, procure, or service on behalf of the Client:

  Commercial General Liability

  Property / Business Property

  Commercial Auto / Fleet

  Workers' Compensation

  Cyber Liability / Data Breach

  Other:

Exclusions / Limitations

Beneficiary Designation (If Applicable)

Broker Information

Authorization and Consent

By signing below, the Applicant authorizes the Broker identified above to act as the Applicant's insurance broker of record for the coverages and policy(ies) identified in this form. This authorization includes, but is not limited to, the authority to:

• Obtain quotations, negotiate terms, and recommend coverage placements on the Applicant's behalf;
• Receive policy documents, renewal notices, premium statements, and claims information from insurers and third-party administrators;
• Communicate with prior carriers and third parties to obtain underwriting and claims history necessary for underwriting and servicing;
• Receive commissions and fees customary to the insurance industry as disclosed by the Broker to the Applicant.

This consent does not, unless expressly stated in writing, permit the Broker to: bind coverage in excess of any limits set forth by the Applicant; settle claims without express written authority; or modify policy terms and conditions without the Applicant's written approval.

  I authorize insurers, prior carriers, and administrators to release underwriting, policy, and claims information to the Broker named above.

  I authorize the Broker to obtain quotes and negotiate terms on my behalf.

  I authorize the Broker to bind coverage where written binding authority has been granted by the insurer and disclosed to me in writing.

Fees, Commissions, and Conflicts of Interest

The Broker may receive commissions, fees, or other remuneration from insurers in connection with the placement or servicing of the Applicant's insurance. The Broker shall disclose known material conflicts of interest upon request. The Applicant acknowledges receipt of any standard commission disclosure provided at or prior to engagement.

  I acknowledge that the Broker may receive commissions or fees from insurers.    If a specific commission or fee has been agreed, state percentage:

  I acknowledge that I have been offered the opportunity to discuss potential conflicts of interest and the Broker's compensation arrangements.

Data Protection and Privacy

The Applicant authorizes the collection, use, retention, and disclosure of personal and business information necessary for placement, underwriting and administration of insurance coverages. The Broker will handle such information in accordance with applicable privacy obligations. The Applicant's consent remains effective until revoked in writing; however revocation will not apply to information already disclosed or to obligations under any executed policy.

  I acknowledge the data handling and privacy provisions set forth above.

Duration and Termination

This Consent is effective as of: and remains in effect until revoked in writing by the Applicant. Revocation will not affect transactions or disclosures made prior to receipt of the revocation.

Declarations and Certifications

I certify that the information provided in this form is true and complete to the best of my knowledge. I understand that the Broker will rely on this authorization in placing and servicing insurance coverage. I acknowledge that signature of this form constitutes my express consent for the Broker to act as my insurance representative as described herein.

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