Agent of Record Request

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.

Reason(s) for Agent Change:

Customer Moved Discourteous Agent/Agency
Agent Moved Unsatisfactory Service
Long Dist and/or Convenience Personal Preference
One agent for all policies Agent retired or left Company
Suggested by Agent
Suggested by Agent of Record