Home Advocate Insurance Group

6250 Old Dobbin Ln, Suite 100, Columbia, MD 21045
Phone: (443) 430-2390 | Toll Free: (877) 487-8341
Fax: (866) 922-3014 | info@homeadvocate.net

For your convenience, you can fill one out the form below appointing our agency as your exclusive agent of record. Once we receive your online submission, we will fax you a copy to obtain your signature. Please fax back to us at your earliest convenience.

General Information

Date:

Re:

Name Insured:

Type of Policy:

Insurance Company:

Policy Number:

Office Phone:

Home Phone:

Best Time To Call:

am pm

Dear Underwriter:

Effective I appoint Home Advocate, LLC as my exclusive agent of record for the captioned policy and permission is granted to develop underwriting information for our insurance account.

This appointment rescinds all previous appointments and the authority granted will remain in force until cancelled in writing.

Reason for Agent Change:

Customer Moved
Agent Moved
Long Dist and/or Convenience
One agent for all policies
Suggested by Agent
Suggested by Agent of Record

Discourteous Agent/Agency
Unsatisfactory Service
Personal Preference
Agent retired or left Company
Suggested by Management
Other (Please explain in remarks)

Additional comments

_______________________________________________
(Signature)

(Print Name)

(Title, if applicable)

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Home Advocate, LLC is a proud member of the Independent Insurance Agents & Brokers of America			Privacy Policies \| info@homeadvocate.net Phone: (443) 430-2390 \| Toll Free: (877) 487-8341 \| Fax: (866) 922-3014