Broker of Record and Non-Solicitation Statement

Date

MonthDayYear
Date
Company Name
Decision Maker's Name

First NameLast Name
Decision Maker's Title
Agent's Name

First NameLast Name
Signed

Clear
Company Name: {companyName}

Decision Maker's Name: {decisionMakers}

Decision Maker's Title: {decisionMakers4}

Broker of Record Change and Non-Solicitation Statement

To all insurance carriers pertaining to us and receiving this notice:

Please be advised that we wish to name {agentsName} (producer) as our exclusive broker representative effective {date} for all worksite voluntary benefits, to include but not limited to Accident, Cancer, Critical Illness, Disability, Life, Dental, Vision, currently in force or submitted by application.

This authorization replaces any other authorization that may have been previously completed for any other insurance representative for the stated lines of business.

Non-Solicitation Statement:

I, {decisionMakers} wish for {agentsName} to be my insurance agent as indicated in the Broker of Record Statement above. {agentsName} did not solicit our business but we reached out to them.

{signed}

{date}
Should be Empty: