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Fillable AGENT/BROKER OF RECORD CHANGE - pmtins .com

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ACORD PRODUCER TM AGENT/BROKER OF RECORD CHANGE INSURANCE COMPANY NAME DATE CODE: AGENCY CUSTOMER ID: SUBCODE: POLICY NUMBER(S) EFFECTIVE DATE EXPIRATION DATE LINE OF BUSINESS Please be advised that we wish to name CODE # PRODUCER DATE as our exclusive representative effective for the lines of business shown above, currently in force or submitted by application. This authorization replaces any other...
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