If you wish to have our agency take over the servicing of an existing policy please copy and paste the letter below on your company letterhead. If individual policies, please enter your Name, Address, City, State, and Zip. Please note to replace date and list insurance companies and policy numbers you wish to have us assume.
Once completed and signed, mail or fax the form to us at Insru-West 380 South 200 West. P.O. Box 977, Farmington, UT 84025. If you would like to fax the form to us our fax number is 801-451-8318.
FOR BUSINESSES PLACE THE LETTER ON YOUR LETTER HEAD
FOR INDIVIDUALS PLEASE ENTER
• NAME
• ADDRESS
• CITY, STATE. ZIP
(DATE)
RE: Appointment of Insur-West, Inc. as our Agent/Broker of Record
To Whom it May Concern:
This will confirm that we have appointed Insur-West, Inc. as our exclusive insurance agent/broker of record for the following policies
1. (COMPANY) – Policy #:
2. (COMPANY) – Policy #:
3. (COMPANY) – Policy #:
The appointment of Insur-West, Inc. rescinds all previous appointments and the authority contained herein shall remain in force until canceled by us in writing.
This letter also constitutes your authority to furnish Insur-West, Inc.’s representative with all information they may request as it pertains to our insurance contracts, rates, reserves, retention, and all other financial data they may wish to obtain for their study of our present and future requirements in connection with our insurance policies.
Sincerely,
(NAME)
(COMPANY / INDIVIDUAL NAME)
(TITLE, IF APPLICABLE)
