For your convenience, you can fill one 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:

Name Insured:
Type of Policy:
Insurance Company:
Policy Number:
Email Address
Day Phone:	Night Phone:
Best Time To Call:	AM   PM

Dear Underwriter:

Effective I appoint Corcoran & Mann 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:

(Name) (Title, if applicable)