Broker of Record Form

Do you want Deland, Gibson to handle your insurance policies? We are happy to do so but you must first authorize us by completing the steps below.

  • Copy the text below in the black box and paste it into your own letterhead.
  • Edit the bolded text fields to contain your information.
  • Create a fax coversheet that includes:
  • Your name and address
  • Name, address and policy numbers for each insurance company you wish for us to represent your interests
  • Your decision maker’s name and title
  • Fax the letter and coversheet to 781-237-1805