AGENT OF RECORD LETTER


Date:__________________



(Current Insurance Company)

_______________________________


RE: Company Name:________________________Policy #________________________


To Whom It May Concern:

We have, effective this date, appointed Joe M. Baselice through Black, Gould & Associates, Inc. of Phoenix, Arizona as our sole insurance representative to handle our Group and Employee Benefits insurance. This document will supersede all other letters prior to this date. They are authorized to work with you in any of the insurance requirements connected with our insurance plans.

Please accept them in such capacity and provide such information and records or make such endorsements, alterations and changes as they may request. This also is to authorize payment to them of such commission and allowances as are now provided or may be provided in the future under any and all group policies we have with your company.

The authority vested in them with this appointment is to continue until such time as you may be otherwise notified differently in writing by this office.

Sincerely,



Company Officer