Agent of Record Request

For your convenience, you can fill out the form below appointing Rekerdres Insurance 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.

PERSONAL INFORMATION
Name:
Title (if applicable):
Email:
Home Phone:
Work Phone:
Address:
City:
State:
Zip:
Preferred Contact:

Effective I appoint REKERDRES INSURANCE 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 canceled in writing.
REASON(S) FOR AGENT CHANGE
Customer Moved Discourteous Agent/Agency
Agent Moved Unsatisfactory Service
Long Distance and/or convenience Personal Preference
One agent for all policies Agent retired or left company
Suggested by Agent Suggested by Management
Suggested by Agent of Record Other (explain below)

Remarks:

Click "submit" to send your request


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last updated 3-may-03