Insurance Unsigned AOR

INSURANCE AGENT OF RECORD AUTHORIZATION (UNSIGNED AOR)

Client Name:     Policy Number:

Insured Information

Policy Details

Policy Type:     Coverage Amount:

Deductible:     Annual Premium:

Policy Period: From to

Current Agent / New Agent

New Agent Phone:     License/NAIC#:

Scope of Authorization (select all that apply)

  Execute endorsements and policy changes necessary to place or service coverage
  Receive and remit premium notices and billing information
  Report and manage claims, obtain claim files and status
  Request and obtain certificates of insurance and evidence of coverage
  Address billing and account inquiries with carriers
  Obtain policy documents, endorsements, binders and related records

Exclusions and Limitations

The agent is NOT authorized to bind new coverage beyond existing authority, alter limits or endorsements that increase carrier liability without express written consent from the insured. Specific restrictions:

Beneficiary Designation (if applicable)

Beneficiary Name:    Relationship:    Percentage:

Beneficiary Name (2):    Relationship:    Percentage:

Acknowledgment and Authorization

I hereby appoint the New Agent/Agency named above as my Agent of Record with respect to the policy identified in this authorization. This appointment authorizes the New Agent to receive policy information, request certificates, discuss policy terms with the carrier, and otherwise act within the scope selected above. This authorization does not amend or modify policy terms or create new coverage obligations by the insurer absent carrier acceptance.

I authorize any insurance carrier, agency, or producer to release policy information and records to the New Agent to the extent necessary for the performance of authorized duties. I understand that this authorization remains in effect until revoked in writing and accepted by the insurer, and that prior carriers may rely on this authorization during the processing period.

Certification, Indemnity, and Legal Notices

The undersigned certifies that the information provided herein is true and correct to the best of their knowledge and that they are authorized to execute this authorization on behalf of the named insured. The undersigned acknowledges that execution of this form may affect the payment of commissions or fees to agents and that such matters are subject to the terms of broker/carrier agreements.

The undersigned agrees to indemnify and hold harmless the carrier and any previous agent for actions reasonably taken in reliance upon this authorization until a carrier confirms acceptance of a change in agent. This authorization is governed by the laws applicable to the insured property or the situs of risk unless otherwise specified by contract.

Reason for Change (brief)

By signing below, I authorize release of policy information as stated above and confirm that I understand the implications of this Agent of Record authorization. I further certify that I have authority to execute this document for the insured named above.

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