If you would like us to manage your insurance policy, you will need to complete the following document. Please print, complete, and sign the following document.  Please mail to our address at 357 Beach Road, Burlingame, CA 94010.   Thank you.

(YOUR COMPANY LETTERHEAD HERE)

Today's Date:  __________________

Insurance Company:______________________ Policy #___________________________

AUTHORIZATION FOR CHANGE OF BROKER

We hereby appoint Agents & Brokers of California., 357 Beach Road, Burlingame, CA 94010, (650) 344-6724 as our exclusive insurance broker/agent of record with regard to the above captioned. This appointment cancels and supersedes any prior appointments or authorizations and remains in force until cancelled by us in writing.

This letter further constitutes your authority to furnish Agents & Brokers of California all information they may request as it may pertain to our insurance. This appointment is to take effect as of the date of this letter.

We recognize and understand that Agents & Brokers of California will not share responsibilities for any deficiencies in the insurance program to which this letter of authority applies until they have had a reasonable opportunity to review all contracts referenced herein and other relevant data and to make their presentation, coverage summary, and recommendations to us.

Date:_______________          Signature :________________________________

Signed by:_____________________________________  Title:_______________