Authorization to Obtain Loss Runs | Deerfield Advisors Insurance Agency

Business Name
Physical Address
Phone Number
Insurance Company
Policy Number
To Whom It May Concern

In accordance with related Department of Insurance code, I hereby request a copy of my entire Loss History / Loss Runs for the policy/policies listed above and any other policies that pertain to my organization. Please do not delay forwarding this information or contact the current agent of record regarding our request, as doing so may delay our receipt and could constitute an "unfair business practice" should we be kept from our ability to go out to market.

We kindly request that you fax this information to my attention at 713-589-7969 ASAP. Should you have any questions, please call me at the phone number listed above.

Thank you, in advance for your immediate attention and cooperation in this matter.

Sincerely,
Signature*
Name*