About this template
A Broker of Record (BOR) form is a legally significant document used by policyholders to officially authorize an insurance agent or brokerage to represent them and manage their insurance policies. This designates a specific professional to handle renewals, quotes, claims communication, and policy servicing with the insurance carrier.
Using Doc2Form, you can instantly turn this standard insurance template into a live Google Form, making it effortless for clients to submit their official brokerage designation online. The form collects essential information including current policy details, insurance company names, new agent credentials, and formal acknowledgments. By moving this process to a digital workflow, agencies can reduce paperwork delays, ensure all necessary compliance details are captured accurately, and maintain clear records of client authorizations.
Whether you are onboarding a new commercial client or taking over personal lines accounts, this structured template ensures you gather every required piece of data cleanly before submitting the change to the carrier.
Key features
- Capture policy numbers and carrier names accurately.
- Collect verified contact details and physical addresses from the insured.
- Streamline agent transitions with clear authorization language.
- Deploy instantly as a Google Form using Doc2Form.
Use cases
Commercial clients transferring policy management to a new advisory f…
Commercial clients transferring policy management to a new advisory firm.
Individual policyholders updating their designated insurance agent of…
Individual policyholders updating their designated insurance agent of record.
Annual policy reviews requiring formal broker re-appointment.
What this form collects
- Insured Name (Short answer)Enter the full legal name of the policyholder or company.
- Insured Address (Paragraph)Provide the primary mailing address associated with the policy.
- Email Address (Short answer)Enter the primary email address for policy communications.
- Phone Number (Short answer)Provide a reliable phone number where we can reach you.
- Insurance Company Name (Short answer)Name of the current insurance carrier providing coverage.
- Policy Number (Short answer)Enter your current policy number or numbers.
- New Agent Name (Short answer)Full name of the newly appointed agent or brokerage.
- Effective Date of Appointment (Date)Select the date you want this broker designation to take effect.
- Authorization Acknowledgment (Multiple choice)By submitting this form, you revoke all previous broker of record appointments and authorize the named agent to represent you.
- Insured's Signature (Short answer)Please type your full legal name to serve as your electronic signature.
FAQ
What is a Broker of Record form?
It is an official document where a policyholder names a specific insurance agent or brokerage to act on their behalf with the insurance carrier.
How do I share this form with my clients?
Once generated in Google Forms, you can easily email the form link to your clients or embed it directly on your agency website.
Can I customize the questions on this template?
Yes! Because it is a native Google Form, you can add, remove, or edit any fields to match your agency's specific workflow requirements.
How does Doc2Form help me set this up?
Doc2Form instantly converts structured document templates into fully functional Google Forms in seconds, saving you hours of manual form building.
Get this form in your Google Drive
Save a copy to your Google Drive with one click (uses 1 credit). Or build from a PDF or description in the app.