DB Binder Request Deborah Heggs-Alston 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) Deborah Heggs-Alston Independent insurance Agent Licensed in Maryland with the department of insurance License number 3000190080 and Universal Marketing and Management INC. an online search platform. 2. (The Client) appoints Agent as (The Client)'s insurance Agent of record. 3. An annual audit will be conducted on all policies before renewal. This is to insure all information is current and correct. 4. Annual service charge fee will be charged upon renewal of policy. 5. This agreement shall become operative on the (Effective date) and shall continue in full force until terminated by either party. I Agree Disagree Date: Signature
