Abbott Insurance Agency: Transfer A Policy - Agent of Record Change Request Form

Call Us:

Lyndhurst: (201) 933-3333

Bloomfield: (973) 566-6666

Agent of Record Change Request Form

For your convenience, you can fill out the form below appointing our agency as your exclusive agent of record. Once we receive your online submission, we will fax you a copy to obtain your signature. Please fax back to us at your earliest convenience.

Re: Name Insured:

Type of Policy:

Insurance Company:

Policy Number:

Day Phone: Night Phone:

Best Time To Call: AM PM

Dear Underwriter:

Effective I appoint Abbott Insurance Agency as my exclusive agent of record for the captioned policy and permission is granted to develop 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:

Customer Moved
Agent Moved
Long Dist and/or Convenience
One agent for all policies
Suggested by Agent
Suggested by Agent of Record Discourteous Agent/Agency
Unsatisfactory Service
Personal Preference
Agent retired or left Company
Suggested by Management
Other (Please explain in remarks)

Remarks:

(Print Name)

(Title, if applicable)

About Us | Online Services | Contact Us | Quote Me Today | Products

Wedding Ring Insurance | Our Companies | My Home's Value

Se Habla Espanol | Transfer a Policy | Refer a Friend | Directions

Return Home

Lyndhurst, NJ Office

705 Ridge Road
Lyndhurst, NJ 07071

Phone:
Fax: (201) 933-3333
(201) 933-0331

Bloomfield, NJ Office

219 Bloomfield Avenue
Bloomfield, NJ 07003

Phone:
Fax: (973) 566-6666
(973) 566-9124

Email: 705@abbottinsuranceagency.com

Important Note: This website provides only a simplified description of coverages and is not a statement of contract. Coverage may not apply in all states. For complete details of coverages, conditions, limits and losses not covered, be sure to read the policy, including all endorsements.

	© Copyright Abbott Insurance Agency