Ellevate Insurance

Broker of Record Authorization

Erlynne Massie, Individual Producer · Individual NPN 1325655
Agency NPN 22181031 · Erlynne Massie LLC dba Ellevate Insurance

By completing this form, I confirm that I would like Erlynne Massie of Ellevate Insurance to be my agent (Broker of Record), and that I am making this request voluntarily and directly.

Client Information

First Name *

Last Name *

Date of Birth *

Phone Number *

Email Address *

Household Status

Marital / Household Status *

Home Address

Street Address *

Apt / Unit / Suite

City *

State *

ZIP Code *

Authorization & Consent

I, the undersigned insured, hereby confirm that I personally initiated contact with Erlynne Massie and requested that she become my Broker of Record. I am making this request voluntarily and of my own choosing. This request was not solicited, induced, pressured, or coerced by Erlynne Massie or her agency. I understand that this Broker of Record change will replace my current broker/agent of record for the applicable policy or policies, subject to carrier approval and any carrier-specific requirements.

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I have read and agree to the above authorization. I confirm I am requesting Erlynne Massie as my Broker of Record of my own free will. *

Client Signature

Type your full legal name below as your electronic signature.

Client Signature (Typed Full Name) *

Date *

Ellevate Insurance • Agent@EllevateInsurance.com • 480-971-0600

NPN 1325655 • Licensed in All 50 States + DC