Walter L. Clark & Associates: Agent of Record Request

Agent of Record Request

For your convenience, you can fill out the form below appointing our agency as your exclusive agent of record. Once we receive your online submission, we will fax you a copy to obtain your signature. Please fax back to us at your earliest convenience.

Date:

Re: Name Insured:

Type of Policy:

Insurance Company:

Policy Number:

Day Phone: Night Phone:

Best Time To Call: AM PM

Dear Underwriter:

Effective I appoint Walter L. Clark & Associates, Inc. as my exclusive agent of record for the captioned policy and permission is granted to develop underwriting information for our insurance account.

This appointment rescinds all previous appointments and the authority granted will remain in force until cancelled in writing.

Reason(s) for Agent Change:

Customer Moved
Agent Moved
Long Dist and/or Convenience
One agent for all policies
Suggested by Agent
Suggested by Agent of Record Discourteous Agent/Agency
Unsatisfactory Service
Personal Preference
Agent retired or left Company
Suggested by Management
Other (Please explain in remarks)

Remarks:

_______________________________________________
(Signature)

(Print Name)

(Title, if applicable)

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