Date:

Dear Underwriter:

Effective I appoint Partners Workplace Solutions Group as my exclusive agent of record for the captioned policy(ies) 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.

Partners Workplace Solutions Group is authorized to negotiate with any insurance company pertaining to the captioned policy(ies) and shall not be responsible for any return commissions, uncollected premiums, audits or other financial arrangements nor for any current coverage deficiencies in the captioned policy(ies).

This letter also authorizes any underwriter to furnish Partners Workplace Solutions Group representatives with any information pertaining to insurance contracts, rates, schedules, surveys, reserves, losses, retention or financial data relevant to the captioned policy(ies).

You also acknowledge and agree that we are not responsible for the actions and decisions of the previous agency, agent or it’s employees regarding the captioned policy(ies).

We acknowledge and agree that Partners Workplace Solutions Group makes no representation as to the availability of insurance coverage or the reasonableness of it’s terms.