Insurance Change of Agent

Insurance Change of Agent

Client Name:   Policy Number:

Applicant / Insured Information

Date of Birth:   Phone:   Email:

Policy Details

Insurer Name:

Homeowners    Automobile    Commercial Property    General Liability    Life    Other:

Coverage Limit: $   Deductible: $   Annual Premium: $

Policy Period: From to

Current Agent Information

License Number:   Contact Phone:

Terminated by insurer    Requested by insured    Agent retirement    Agency reassignment    Other reason:

New Agent Appointment

License Number:   Contact Phone:

Effective Date of Appointment:

Policy servicing    Claims handling    Billing and premium payment authority    Endorsement processing    Limited authority (describe below)

Authorize new agent to receive policy documents and information: Yes    No

Coverage / Service Transfer

Policy servicing    Premium collection    Claims notice    Endorsements    Cancellation / nonrenewal notices

Exclusions and Limitations

The change of agent does not amend the terms, coverages, limits, conditions, endorsements or premiums of the policy except as explicitly acknowledged in writing by the insurer. The insurer retains sole authority to accept or reject any claim, endorsement request, cancellation, or reinstatement unless otherwise provided by law or by an express written delegation to the new agent.

Beneficiary Information (if applicable)

Relationship:   Percent of Benefit: %

Attachments / Documentation Checklist

The following documents are required to process this change. Check those attached:

Agent appointment letter    Signed agency agreement    Copy of agent license    Power of attorney (if applicable)

Declaration and Certification

By signing below, the undersigned certifies under penalty of law that the information provided in this Insurance Change of Agent form is true, complete and accurate to the best of the undersigned's knowledge. The undersigned represents that they are authorized to request the change of agent on behalf of the named insured or policyholder. The undersigned authorizes the current agent and insurer to release policy information, claims history, and related records to the new agent named in this form to the extent necessary to effectuate servicing and administration of the policy.

The undersigned acknowledges that the insurer may require additional documentation to effectuate this change and that processing of this request does not constitute acceptance of any endorsement, new coverage or change to policy terms unless expressly documented by the insurer. The undersigned agrees to indemnify and hold harmless the insurer from any liability arising from acts performed by the new agent pursuant to the authority granted herein, except to the extent caused by the insurer's own gross negligence or willful misconduct.

Authorization to Release Records

The undersigned authorizes the insurer and its representatives to disclose information regarding the policy, claims, and underwriting to the new agent identified in this form. This authorization remains in effect until revoked in writing by the undersigned, provided that revocation will not affect disclosures made prior to receipt of the revocation.

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