Broker of Record Procedure

If you wish to have our agency take over the servicing of an existing policy please copy the letter below and paste onto a word document. Then please fill in your company and insurance information as required by the paranthesis (...), sign, and fax to our office at 800-980-1960. If you have any questions while completing this form please feel free to call our office at 800-980-1950.

(DATE)

(COMPANY NAME)

(OWNER'S NAME)

(ADDRESS)
(CITY, STATE. ZIP)

RE: Appointment of American Business Insurance Services, Inc. as our Agent/Broker of Record

To Whom it May Concern:

This will confirm, effective immediately, we hereby appoint American Business Insurance Services, Inc. as our exclusive insurance agent/broker of record for the following policies:

(NAME OF INSURANCE COMPANY) - (POLICY NUMBER)

The appointment of American Business Insurance Services, Inc. rescinds all previous appointments and the authority contained herein shall remain in force until canceled by us in writing.

This letter also constitutes your authority to furnish American Business Insurance Services, Inc. with all information they may request as it pertains to our insurance contracts, rates, reserves, retention, loss runs & information, copy of the insurance application used to procure above referenced insurance policy, copy of insurance policy, all endorsements processed todate and any other financial data they may wish to obtain for their study of our present and future requirements in connection with our insurance policies.

Sincerely,

(OWNER'S NAME)

(TITLE)
(COMPANY NAME)