AGENT OF RECORD LETTER
INDIVIDUAL

In connection with my current company______________________________, Policy#____________________________, I designate Joe M. Baselice as my agent of record through Black, Gould and Associates, Inc.

I understand that the agent named herein will now receive all commissions and will be responsible for all y servicing needs.

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PRINT CLIENT NAME
 

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SOCIAL SECURITY NUMBER
 

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DAYTIME PHONE NUMBER
 

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PHYSICAL STREET ADDRESS
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SIGNATURE                                               DATE


*PLEASE FAX DIRECTLY TO (480) 940-8107