Broker of Record Form Admin
Broker of Record Form
April 3, 2012 JOHN SMITH MANUFACTURING 123 Massachusetts Avenue BOSTON, MA 02XXX
RE: Broker of Record Authorization
Policy # XXXXXXXXXXXXXX
Dear Sir/Madam: Please be advised that Deland, Gibson Insurance Associates, Inc., 36 Washington Street, Wellesley Hills, MA 02481 has been appointed as our exclusive insurance broker to represent us in all matters pertaining to our insurance programs. This appointment is effective as of this date and shall remain in effect until notification, in writing, to the contrary is provided to you. This appointment supersedes and replaces all other appointments and all other letters of authority on record with you.We authorize you to provide Deland, Gibson Insurance Associates, Inc., 36 Washington Street, Wellesley Hills, MA 02481 with any and all information pertaining to our contracts of insurance, rates, losses, reserves, etc., that may be necessary for them to become completely familiar with our insurance program and to effectively represent our current and future insurance and service interests.
Furthermore, we agree that Deland, Gibson Insurance Associates, Inc., 36 Washington Street, Wellesley Hills, MA 02481 is not responsible for any deficiencies in our present insurance program and will not assume any such responsibility until they have had reasonable opportunity to review, provide us with recommendations, and arrange any changes in coverage that we authorize.
If you have any questions regarding this appointment/authorization, please do not hesitate to contact me. Thank you for your attention in this matter.
JOHN DOE CFO
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