Agent of Record Change
What insurance carrier(s) do you currently have?
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Progressive
Safeco
National General (NatGen)
Nationwide
Openly
Branch
Travelers
Hagerty
MetLife/Foremost360
Other
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Name
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First Name
Last Name
Cell Phone Number
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Please enter a valid phone number.
Email
*
example@example.com
Current Policy Number(s)
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If you have policies w more than one carrier, please specify which policy number is with which carrier.
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By signing this document, policyholder appoints The Region Insurance Agency as their exclusive insurance agent, granting authorization to represent them in all insurance matters, including policy analysis, recommendations, and claims assistance.
*
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Thank you for your business!
You will receive a copy of this form in your email. You may also receive an email from your carrier and from The Region Insurance Agency confirming your agent change. Please reach out to us with any questions or concerns.
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