Agent of Record
Ideal Insurance Agency Agent of Record
Insurance Company: _________________________ Date: ______________
Name of Insured: ____________________________
Policy Number(s): ___________________________
To Whom it May Concern:
Effective immediately, please recognize Ideal Insurance Agency as the agent/broker of record
for all matters pertaining to the above mentioned policy or policies with your company. This
appointment is effective immediately and will remain in full force and effect until you are notified in
writing to the contrary.
If you have any questions regarding this authorization, please do not hesitate to contact me.
Thank you for your cooperation and assistance in this matter.
Print name: __________________________
Please mail, fax, or email this form to:
Ideal Insurance Agency
601 Carlson Parkway #1050
Minnetonka MN 55305