Acord 36 Insurance Form

Date mm dd yyyy agency phone insurance company name a c no ext.

Acord 36 insurance form. Named insured effective expiration line of business policy number s as it appears on policy date date please be advised that we wish to name producer as our exclusive representative. Use acord 36 to provide authorization from your customer to the customer s current. Exclusive representative with respect to policies currently in force. Policy number s effective date expiration date line of business.

The acord name and logo are registered marks of acord applicant information underwriter underwriter office commercial insurance application date mm dd yyyy applicant information section fax a c no. The acord name and logo are registered marks of acord acord 36 2007 01 current agency current producer insurance company name city of insured state of insured zip code of insured street address of insured title if applicable company name if applicable stated lines of business. Agent broker of record change please be advised that we wish to name as our exclusive representative effective for the lines of business shown above currently in force or submitted by. New agency insurance company namephone a c no ext.

By law we must report the termination of auto insurance coverage to the department of motor vehicles. Acord forms increase your efficiency. Remarks acord 101 additional remarks schedule may be attached if more space is required policy number effective date company subject to audit premium calculation. Previously completed for any other insurance representative.

Previously completed for any other insurance representative for the stated lines of business. Since our first paper form was released in 1972 acord has provided the standard forms used by the insurance industry. Acord 36 2007 01 agent broker of record change. Company name if applicable title if applicable street address of insured city of insured state of insured zip code of insured insurance company name current agency current producer acord 36 2007 01 the acord name and logo are registered marks of.

Surrender your registration certificate and plates before your insurance expires. Contact a c no ext. The form notifies the insurer that you have been named as the.