Agent-Broker of Record Change Letter

Use Company or Personal Letterhead.

[Date]

[Your Name (Company Officer/Requesting Individual)]
[Company Name (If applicable)]
[Street Address]
[City State ZIP Code]

[Recipient Name (If available)]
[Title]
[Company Name]
[Street Address]
[City State ZIP Code]

Re: Agent/Broker of Record Change

For: [Name of Policy/Contract Holder and Policy Number]

To whom it may concern:

We would like to change our servicing agent for [Contract Holder Name], and therefore we hereby request that [Agent/Broker Name] be our new broker/agent of record for policy number [Policy Number], as of [Effective Date].

If you have any questions, call me at [Phone Number] and/or send me an e-mail at [E-mail Address].

Sincerely,
[Your Name]
[Title]