| 14221 Euclid Street Unit J, Garden Grove, CA 92843 Bus: (714) 539-8484 Fax (714) 539-5484 Email: nic@gtinsurance.net License # 0H65115 |
BROKER OF RECORD
Date: __________________
C/O GT INSURANCE AGENCY INC
____________________________
Company’s Name
____________________________
Address
____________________________
City, States, Zip
RE: __________________________________________________
Policy Number
Insured’s Name__________________________________
Effective: ________________________
Date
To Whom It May Concern:
I hereby appoint GT INSURANCE AGENCY INC as my sole Broker to act as my exclusive representative in regards
to my ________________________ insurance. This authorization shall remain in effect until superseded
or revoked by the undersigned. Please forward my original application and any pertinent information to my
new agent.
Sincerely,
_______________________________________ __________________________
Insured’s Signature Date/Time