Agency Change Request -

Step 1 of 6

Requesting Party

Your contact details, and the agency you are acting for in this transaction.

Name Required

Title Required

Email Required

Direct telephone RequiredUsed for verification on remittance changes.

Capacity

You are submitting this request on behalf of Required

The acquiring agencyThe agency taking on the business The transferring agencyThe agency currently of record Both — common ownershipThe same principals on both sides A representativeCounsel, consultant or carrier representative

Step 2 of 6

Nature of Request

Select every transaction that applies. A single agreement often produces more than one, and your selections decide the steps and documents that follow.

Transaction type Select at least one

Agency acquisition or mergerOne agency has acquired, merged with, or absorbed another Book of business or broker of record transferPolicies are moving from one agency to another Change of legal name or DBAThe same legal entity trading under a different name Change of W-9, tax identification or entity typeA new taxpayer identification number, or a change of corporate structure Change of commission payee or remittance detailsWhere and to whom commission is paid Update to agency contact or licensing recordsAddress, telephone, contact or licence details

Timing

Primary transaction Required Where several apply, select the transaction that gave rise to the others.

Requested effective date Required The date the change takes effect, not the date of this request.

Requested handling Required

StandardNo deadline within the next 30 days Renewal pendingAffected policies renew within 30 days Deadline drivenA closing or filing date governs the timing

In your own words

Description of the transaction Required This is the first thing our team reads. A plain description is more useful to us than formal wording. Please do not include tax identification or bank account numbers.

Step 3 of 6

What Is Changing

The particulars of each transaction you selected.

Transfer of business

Authority for the transfer Required

Broker of record letter signed by the insuredThe policyholder is appointing a new broker. Applies to the accounts named in the letter. Purchase or assignment signed by the transferring agencyThe agency has sold or assigned the business BothAn agency assignment together with individual broker of record letters

A broker of record letter is signed by the insured and moves that account. An assignment is signed by the transferring agency and moves the business it describes.

Business included in the transfer Required

The entire book Specified policies only Specified programs or lines The entire book, with exceptions

Step 4 of 6

Agencies Involved

The agency taking the business on, and the agency it is coming from.

Acquiring agency — the agency that will hold the business

Legal name RequiredExactly as it appears on the W-9, including Inc., LLC or LP.

Doing business as If applicable

Is this agency appointed with Greenwood? Required

YesWe already place business with Greenwood NoIncluding an entity newly formed for this transaction Not certainWe will check our records

Principal or owner Required

Principal’s email Required

Mailing address Required

Transferring agency — the agency currently of record

Legal name Required

Greenwood agency code If known

Principal or owner Required

Principal’s email RequiredWe may contact them to confirm the transfer.

Status of this agency following the transaction Required

It will be dissolved It will continue as a subsidiary or affiliate It will continue trading — only the book was sold Not yet determined

The transferring agency is aware of this request and consents to itWe verify any transfer that appears to be in dispute before acting.

Step 5 of 6

Supporting Documents

Based on what you have told us, these are the documents we will need. Incomplete documentation is the most common reason a request is delayed — attach what you can now.

PDF, JPG, PNG, Word, Excel or CSV. Documents are held securely and seen only by Greenwood staff handling your request.

Step 6 of 6

Review & Submit

Please read your request before submitting — this is the record of what you have asked us to do.

Your request

Authorization — to be completed by a principal or an officer with authority to bind the agency

Name Required

Title Required

I have authority to bind the agency named in this request Required The information given is accurate and the attached documents are true copies Required I understand that no change takes effect until Greenwood confirms it in writing RequiredThis form is a request for a change, not an instruction that takes effect on submission.

Signature — type your full name Required

Date Required

Agency Change Request

Requesting Party

Nature of Request

What Is Changing

Agencies Involved

Supporting Documents

Review & Submit

Thank you — we have your request

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