Sample Broker-Of-Record Letter


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RE: Insurance Policies Listed by Policy #, Insurance Company, Effective Dates, and Type of Insurance

To whom it might concern:

As of this date, AGENCY NAME is appointed Broker/Agent of Record for INSURED with respect to its TYPE Insurance Program (“Coverage”) listed above. This appointment rescinds all previous appointments, if any; and this authorization will remain in full force and effect until canceled in writing by us.

This letter authorizes AGENCY NAME to negotiate with any insurance carrier with respect to the Coverage. However, AGENCY NAME will not be responsible for any deficiencies in, or any return premiums and/or commissions due, on any insurance not placed by AGENCY NAME.

This letter also authorizes any underwriter to furnish AGENCY NAME representatives with all information on any and all insurance contracts, rates, rating schedules, surveys, reserves, retention, or other data related to this Coverage that they might need.

AGENCY NAME has made no representation about the availability of insurance coverage, the reasonableness of its terms, or the financial solvency of any insurer.




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