SAMPLE Broker of Record letter by robpearson

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									                              SAMPLE Broker of Record letter

(Must be on letterhead)

Current date! (Must be received by Everest within 10 days)

Everest National Insurance Company
c/o Northwest Insurance Agency
PO Box 7967
Santa Rosa CA 95407

Re:   Workers’ Compensation Coverage
      Policy #3900001234061 (Especially important if current policy is with Everest)
      Effective xx-xx-xxxx to xx-xx-xxxx (Must be received by Everest at least 13 days in
advance of the Effective Date)

Please recognize the Smith Agency as the Broker or Agent of Record to represent us in regards
to our Workers’ Compensation coverage effective xx-xx-xxxx. (date policy is to be effective).

This authorization supersedes all previous authorizations and remains in force until such time as
revoked in writing by the undersigned.


Title (MUST be owner or officer)

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