Broker of Record Letter

If you would like to have our Brokerage take over the servicing of an existing policy, all you need to do is copy and paste the letter below onto your company
letterhead. Please remember to put the current date and list the insurance company/companies and the policy number(s) assigned to the policy you wish to have
us service.

Once completed and signed,  fax the form to us at (949) 270-3704.
Place your letter head at top of page --------------------------------------------------------------------->

(your)
Name
Address
City, State. Zip Code)

(date) XX/XX/XXXX

RE: Byrne-Kim & Associates Ins Svcs, Inc., as our Agent/Broker of Record

To Whom it May Concern:

This be advised that we wish to name Byrne-Kim & Associates Ins Svcs, Inc., as our exclusive
insurance agent/broker of record for the following policy/Policies

1. (Insurance Company Name) - Policy #:
(if more than one policy and company add as needed)
2. (Insurance Company Name) - Policy #:
3. (Insurance Company Name) - Policy #:

The appointment of Byrne-Kim & Associates Ins Svcs, Inc.,  rescinds all previous appointments, we
also would like to waive the 10 day rescission letter and the authority contained herein shall remain
in force until canceled by us in writing.


Sincerely,



(Your Name)  (Your Title)
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