Agent Change Request
Change Notice:
The purpose of this signed authorization is to replace any existing agent/agency that services the policy/contract with the new agent/agency named below. This document supersedes any previous requests. The effective date of the change will be upon processing by the Home Office.
Policy Information:
Policy Numbers
Policy Owner's Legal Name
Joint Owner's Legal Name (if applicable)
Current Agent Information:
Please provide an explanation of why you are switching agents:
Please complete all known information:
Current Agent's Name
Address
New Agent Information:
Phone No.
Phone No.
Social Sec. No.
Social Sec. No.
GBU Agent No.
Phone No.
Only one agent is allowed to be listed as the primary agent. Please list the primary agent first. Additional agents will only be noted for phone support.
New Agent's Name
Required Signatures:
Agent No.
The policy owner's signature authorizes moving of one or more policies between agents
Owner's Signature
Joint Owner's Signature
FOR HOME OFFICE USE ONLY
Date
Date