SN Binder Request Sunde N Nyah Binder Request Individual or Company Email Contact Name Phone Number Street Address : City State: Zip Code: Please Describe your Business.Please be specific Have you had any claims from your previous Policies Yes No If Yes Please Explain What type of Insurance are you requesting? Authorization to gather & share information needed to shop, purchase, cancel new Insurance Policy per client consent and Standard Service Fee Agreement 1. The parties to this agreement are (The Client),(The agent) JK's Affordable Insurance Agency LLC License Number 40841932. 2. (The Client) appoints Agent as (The Client)'s insurance Agent of record. I Agree Disagree Date: Signature
