Broker of Record Form

As the policy holder, you need to designate a broker of record to manage and represent your insurance policy. Enabling Fisher Insurance to be the agent of record can be done in 3 easy steps using the broker of record form below.

Complete the Fisher Shipping Broker of Record Form in 3 Easy Steps:

  1. Copy the text below and paste it onto your company letterhead.
  2. Edit the important information marked with an asterisk and * – Bolded
  3. Fax or Email your Broker of Record to 508-519-3087 or

Form Text to Copy and Paste onto your Company Letterhead:

 * – Insured Name (As it Appears on your Policy(s))
* – Insured Street (As it Appears on your Policy(s))
* – Insured City, State & Zip (As it Appears on your Policy(s)) 

RE:  Broker of Record Authorization

* –  Insurance Company Name & address (if address is known)

To Whom it May Concern:

Please be advised that as of __* – the date you want to appoint us___ we have appointed Fisher Insurance Agency, Inc., 194 West Street, Suite 7 Milford. MA 01757 as our exclusive insurance broker with respect to the above coverage(s) and who will represent us in all matters pertaining to our insurance program(s).  This appointment shall remain in effect until notification, in writing, to the contrary is provided to you. This appointment supersedes and replaces all other appointments and all other letters of authority on record with you.

We authorize you to provide Fisher Insurance Agency, Inc., 194 West Street, Suite 7 Milford. MA 01757 with any and all information pertaining to our contracts of insurance, rates, losses, reserves, etc., that may be necessary for them to become completely familiar with our insurance program and to effectively represent our current and future insurance and service interests.

Furthermore, we agree that Fisher Insurance Agency, Inc., 194 West Street, Suite 7 Milford. MA 01757 is not responsible for any deficiencies in our present insurance program and will not assume any such responsibility until they have had reasonable opportunity to review and arrange any changes in coverage that we authorize.

If you have any questions regarding this appointment/authorization, please do not hesitate to contact me.  Thank you for your attention in this matter and there will not be a rescinding letter.



* – Your Name 
* – Your Title