GT INSURANCE AGENCY INC
14221 Euclid Street Unit J, Garden Grove, CA 92843
Bus: 714-539-8484 Fax: 714-539-5484
Email: nic@gtinsurance.net
License # 0H65115
POWER OF ATTORNEY/BROKER FEE
AGREEMENT
1. Parties to this agreement are __________________________________________ (client) and GT
Insurance Agency. California Department of Insurance License Number 0F15784 (Broker).
2. Client appoints Broker as Client’s Insurance Broker. I grant to my Broker the authority to sign
documents related to my insurance my name where required with my express verbal authority. This
authority is on insurance matter related to my insurance policies only.
3. This agreement shall become operative on __________ _________, and shall continue in force
until terminated by either party.
4. Client agrees to represent client honestly and competently. Client also understands that the broker
also receives a commission from the Insurer on renewals. No broker fee is charged on renewals.
5. Client agrees to pay Broker a broker fee for Broker’s services. The broker fee is
$ _______. This amount was included in the total quoted on the policy. The broker fee is
refundable if the policy is not issued.
6. Client agrees to pay Broker a processing fee for Broker’s additional and extra work performed.
The processing fee is $_______. This amount was included in the total quoted on the policy. The
processing fee is refundable if the policy is not issued.
7. Broker charges no additional service fees on the policy changed to client by broker during the
policy term.
8. I have been given the Department of Insurance Consumer Guide for Automobile Insurance or
Residential Insurance.
______________________________________ __________________
Client’s Signature Date