(Name)
(Address)
(City), (State), (ZIP)
Effective Date of Authorization:__________________
This will notify you that I/we hereby appoint Dave Johnson Insurance, Inc. whose business address is 324 W Heron, Aberdeen, WA 98520 as my/our Agent of Record, and to act as my/our exclusive representative on the insurance policy(ies) shown below.
Insurance Company Policy Number Renewal Date
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Signature & Title Date
Contact Phone:___________________________
