Agent/Broker Change request

PLEASE READ THE FOLLOWING CAREFULLY: To change the agent/broker of record on your policy, provide the information below. For this request to be processed it must be complete and accurate, and it must be signed by the Named Insured or an authorized requestor and by the new agent/broker.

1) You are requesting to change the agent/broker of record on your policy. 2) After your request is processed your current agent/broker will no longer be authorized to service your policy, including making changes to and gathering information about your policy. 3) Changing your agent/broker of record should not be an attempt to reduce premium, and changes made to your policy by the new agent/broker of record are subject to an underwriting review by Progressive that could result in a premium increase.

Name Insured(Required)

First Last

Email(Required)

Policy Number(Required)

Current Agency/Broker Information(Required)

Agency/Broker Name: Coordinated Insurance Services Agent/Broker Code: 022WD Producer Name: Brinton James Fuller Agent Address: 5788 South 900 East, Murray, UT 84121 Agent Phone Number: 801-568-9800

Signature of Named Insured or authorized requestor(Required)

Print Name

Date(Required)

AGENT/BROKER ACKNOWLEDGEMENT: Per your Producer’s Agreement you have a duty to comply with our Underwriting Requirements and, after acquiring a policyholder, to immediately obtain all original signed applications, selections and rejections of optional coverages, and all other records relating to the policy. All records must be maintained pursuant to the Producer’s Agreement and all applicable state laws. If attempts to obtain records from the prior agent/broker are unsuccessful, then you must obtain new signature forms from the policyholder for any coverage rejections, lower limit elections, driver exclusions, and payment authorizations. Failure to do so may qualify as an error or omission by your agency and could result in the termination of your Producer’s Agreement.