MVB Bank

Strategic Resources for Your Insurance Agency

Premier Group Insurance

Create a Broker of Record Letter

Please Note: Our system does not capture your client, agency, policy or signature information. For your convenience you may set this up to save on your own browser.

   Check if client will use their own letterhead
Create Letterhead (please input client information)
Name:
Name: (2nd line if needed)
Address:
Address: (2nd line if needed)
City:
State:
Zip:
Phone:
Insurance Company Information
Name:
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Address:
Address: (2nd line if needed)
City:
State:
Zip:
Insurance Agency Information (new broker of record)
Agency Name:
Agency Code:
City:
State:
Zip:
Policy Information
Policy 1
Policy Type:
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Policy Number:
Effective Date:

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Signature Line
Name:
Title (if a commercial account, must be owner or officer):
MKL

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