Insurance Citizens AOR Form

Insurance Citizens AOR Form

1. Applicant / Insured Information

Client Name:

Individual    Corporation    LLC    Trust    Other

Date of Birth:     Policy Number:

2. Agent of Record / Authorized Representative

License Number:     Agency Phone:

Effective Date of Appointment:

Scope of Authority (check all that apply):

All policies and coverages for the insured named above
Specific policy(ies):
Claims handling and claim intake
Billing, premium statements, and payment facilitation
Requesting endorsements, cancellations, and policy changes
Access to loss history and underwriting files
Renewal negotiations and acceptance of renewal terms

3. Policy Details

Policy Period From:    To:

4. Coverage Selections

Select applicable coverages to which this appointment applies:
Property (Building/Contents)
Liability
Flood
Wind / Hurricane
Auto / Commercial Auto
Other:

5. Exclusions and Limitations

This Authorization of Representation does not authorize the agent to: (a) alter policy coverages or limits without the insured's separate written consent; (b) settle litigated matters or waive defenses on behalf of the insured; (c) bind coverage in excess of any applicable underwriting authority; or (d) accept service of suit or otherwise substitute the insurer's notice procedures. The agent's authority is subject to the insurer's underwriting standards and final approvals.

I acknowledge and accept the foregoing exclusions and limitations: Yes

6. Beneficiary / Payee Designation (Optional)

Designated Payee Name:

Relationship to Insured:    Allocation Percentage:

By designating a payee above, the insured authorizes the agent to receive claim payments and settlement correspondence on behalf of the insured only to the extent expressly permitted by law and by the insurer's payment procedures.

7. Authorization and Certification

I, the undersigned insured, hereby appoint the identified agent as my Agent of Record with respect to the insurance policies and coverages identified herein. I authorize my insurer(s) to release policy, billing, claim and underwriting information to the agent, and to accept the agent's requests for policy documents, loss runs and premium statements. This appointment authorizes the agent to act on my behalf to the extent reasonably necessary to carry out the scope of authority selected above.

I certify that I am authorized to grant this appointment and that the information contained in this form is true and correct to the best of my knowledge. I understand that this Authorization of Representation will remain in effect until I revoke it in writing, and that revocation must be delivered to both the agent and the insurer to be effective.

8. Prior Agent of Record

If applicable, indicate whether this appointment supersedes any prior Agent of Record for these policies:
This appointment supersedes and cancels all prior Agent of Record appointments for the policies identified above.
Prior Agent Name (if known):

9. Required Documentation Checklist

The agent may be required to provide one or more of the following documents when submitting this form to the insurer. Please indicate included documents:
Copy of insured photo identification
Copy of policy declaration page
Signed authorization or power of attorney (if required)
Other supporting documentation:

10. Certification and Signature

By signing below I certify under penalty of perjury that I am the named insured or an authorized representative of the named insured, that I have the authority to appoint the Agent of Record as set forth above, and that the statements made in this form are true and correct. I authorize my insurer(s) to accept this appointment and to provide requested information to the agent as permitted by law and insurer practice.

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