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Date
Carrier
Contact Person
Address
City, ST Zip Code
Re: Client
Dear:
Effective immediately we have appointed CBIZ Benefits & Insurance Services, Inc. (“CBIZ”) as
our exclusive insurance broker. The appointment of CBIZ Benefits & Insurance Services, Inc.,
tax identification number 31-1582098, rescinds all previous appointments and the authority
contained herein shall remain in full force until canceled in writing.
This letter constitutes your authority to furnish the representatives of CBIZ all information they
may request as it pertains to our insurance contracts, rates, rating schedules, surveys, reserves,
retention and all other financial data they may wish to obtain for their study of our present and
future requirements in connection with the insurance programs to which this letter applies. CBIZ
is hereby authorized to negotiate directly with any interested company, with respect to changes
in existing insurance policies and in closing, changing, increasing or canceling insurance carried
under temporary binders or cover notes. We understand, however, that CBIZ will not share the
responsibility for any deficiencies in the insurance programs to which this letter applies until
they have had a reasonable opportunity to make a review and to provide us with their
recommendations.
It is understood and CBIZ has disclosed to us that CBIZ may from time to time receive from you
or your insurance company affiliates standard commissions and other compensation and
consideration pursuant to this broker appointment for performing advisory and consultative
services regarding the insurance coverages in force for our group account.
Sincerely,