Agency Name Here

Appointment of Insurance Broker and Fee Agreement

Insurance Coverage

Effective on	, I appoint Agency Name, as my Insurance Broker for my Insurance coverage. I represent that all statements, which I have made to Agency Name, specifically including my claims history, my prior office insurance coverage, and my prior insurance company information, are true and accurate. Agency Name agrees to represent me in good faith in obtaining and servicing the insurance coverage, which I request.

In the event any insurance premium remains unpaid to Agency Name, I authorize Agency Name to order any insurance company with whom Agency Name has made contact on my behalf to cancel any such insurance by issuance of written notice forwarded to my address set forth below, in accordance with the state of California cancellation notice provisions. I further authorize any such insurance company to return all unearned premiums to Agency Name in order to refund any existing credit balance to me. If any insurance procured by me through Agency Name is cancelled or rejected for any underwriting reason, including without limitation as the result of any erroneous information which I have provided to Agency Name, Agency Name is excused and discharged from any further performance as my Broker and in accord with California Law. If such cancellation or rejection is the result of my provision of erroneous information, Agency Name shall not be obligated to obtain similar insurance coverage for me.

Regardless of the reasons for cancellation, rejection, or termination of insurance coverage, I agree the Brokers Fee in the total sum of $150.00 (One Hundred Fifty US Dollars), which Agency Name obtains from me, is fully earned. Also, I understand that Agency Name, from time to time, will be paid a fee by the finance company and that I do not dispute this payment.

Agency Name has advised me that the choice of coverage, limits of liability, and effective date are solely and exclusively my responsibility. The effective date, coverages and/or limits of liability that are stipulated on my application are by my choice and I do not rely upon Agency Name or authorize Agency Name to provide coverages and/or limits I did not choose. I agree to read and review the policy and its limitations, exclusions, and coverages.

Date

Address

City, State, ZIP

Name (Please Print)	Signature

Name of Agent/Broker (Please Print)	Authorized AGENT/BROKER Signature

REV 07/2009	5

REV 09/2009	1

CID Insurance Programs, Inc

ttallarida

2013-07-22

Cristina Cole

CID