To: forms@libardi.com
From: forms@libardi.com
Subject: Web *** Agent of Record Change Form

DATE:[Date]

-----------------------------------------------------

Policy Holder Name:[policyholdername]

Type of Policy:[typeofpolicy]

Insurance Company:[insurancecompany]

Policy Number:[policynumber]

Day Phone:[dayphone]

Fax To Me At:[faxnumber]

Best Time To Call:[besttocall]

Dear Underwriter:

Effective [monthdayyear]                               I appoint Libardi Service Agency, Inc. as my exclusive agent of record for the captioned policy and permission is granted to develope 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:
       [Cluster1]Customer Moved          
       [Cluster2]Agent Moved
       [Cluster3]Discourteous Agent/Agency
       [cluster4]Long Distance and/or Convenience
       [Cluster5]Unsatisfactory Service
       [Cluster6]Personal Preference
       [Cluster7]One Agent for All Policies
       [cluster8]Suggested by Current Agent
       [Cluster9]Agent Retired/Left Company
       [cluster10]Other (please explain )[other]

Name of Applicant:[nameofapplicant]

Title, If Applicable:[title]