SAMPLE AGENT/BROKER OF RECORD LETTER (TO BE SUBMITTED ON GROUP LETTERHEAD ONLY) Date (IMPORTANT) Name of Broker Program Manager Broker Program Manager Company Name Company Street Address Company City, State, Zip Dear Name of Broker Program Manager : This is to notify you that our company has appointed (name of agent), whose business address is (street, city, state, zip code) as our sole insurance representative, with respect to coverage provided to this organization by Insert Company Name effective (month, date, year)..
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