(FOR BUSINESS PLACE THE LETTER ON YOUR LETTER HEAD
--OR--
FOR INDIVIDUALS PLEASE ENTER

NAME
ADDRESS
CITY, STATE. ZIP)

(DATE)

RE: Appointment of The Lombard Street Group as our Agent/Broker of Record

To Whom it May Concern:

This will confirm that we have appointed The Lombard Street Group as our exclusive insurance agent/broker of record for the following policies

1. (COMPANY) - Policy #:
2. (COMPANY) - Policy #:
3. (COMPANY) - Policy #:

The appointment of The Lombard Street Group rescinds all previous appointments and the authority contained herein shall remain in force until canceled by us in writing.

This letter also constitutes your authority to furnish The Lombard Street Group’s representative with all information they may request as it pertains to our insurance contracts, rates, reserves, retention, and all other financial data they may wish to obtain for their study of our present and future requirements in connection with our insurance policies.

Sincerely,

(NAME)
(COMPANY / INDIVIDUAL NAME)
(TITLE, IF APPLICABLE)