Compliance Disclosure

Agent Name:

Client Name:

Current Carrier:

Policy Number:

New Carrier:

Check if this is an:
Existing ClientNew Client

Type of Policy (select one)

Reasons for choosing new carrier (check all that apply)
Underwriting issues/guidelines of existing carrierCoverage differencesService issues

Enter a short explanation of reason(s) for changing carriers

By checking this box, agent declares all of the below items to be true:

  • Rate differential is > 20%
  • Agent made good faith effort to place coverage with existing company
  • Agent will lose account to competitor if not moved