AUTHORIZATION FOR CHANGE OF AGENT OR BROKER
If your property is located in TEXAS and your current policy is written with an Insurance Company that we are appointed with, AND YOU WOULD LIKE Statewide Insurance Specialists TO BE YOUR NEW SERVICING AGENT, then complete the "Broker of Record" form.
First Name:  *
Last Name:  *
Address:  *
 
City:  *
State:  *
Zipcode:  *
   
Email Address:  *
Phone Number:  * 000-000-0000
Insurance Company:  *
Policy Number:  *
Type of policy
To the Insurance Company:

I hereby authorize you to make STATEWIDE INSURANCE SPECIALISTS the agent or broker of record for the above policy. The expiration month of my policy is .
Please make this Agent the Broker on my policy and send them a copy of my policy for their records.

Signature X ___________________________________Date_______________
 
Please print this form, sign and fax it to (972)-550-1660.