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BROKER INFORMATION

Marsh Office

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Marsh Practice

MMA

Marsh Client Executive

Department #

(required)

Producing Office #

(required)

Your Name

Your Telephone Number

Your Fax Number

Your E-Mail Address

(e.g. name@marsh.com)

CLIENT & NAME INSURED INFORMATION

Effective Date of BOR

Client Number (BASYS)

Primary Named Insured
(as it should appear on the policy)

(max. 30 characters)

Subsidiary

(as it should appear on the policy)

(max. 30 characters)

Client Contact Name
(as it should appear on the policy)

(max. 30 characters)

Mailing Address

(as it should appear on the policy)

If the Primary Named Insured entered above is different from the current Declarations Page, please describe in detail the reason for the change.

Is this New, Renewal or Expanded business?

[ Select ] New Renewal Expanded

New - Marsh has been the broker for this client for less then a year

Expanded - Marsh has been the broker for this client for more than a year, but this is the first term for this policy with Marsh

Renewal - Marsh has been the broker for this client for more than 1 year on this policy

Account Revenue Type

[ Select ] Commission Fee - Commission wil be returned Fee - Commission will be retained

Attach Copy of Broker of Record Letter

POLICY INFORMATION

Number of Policies included

with this BOR request

Attach Copy of Expiring Declarations Page

Attach Life of Loan Flood Zone Determination

If the FZD is not available, the Flood Service Center will proceed with your request,
however an FZD will be required within 30 days of our filing the BOR.

Attach an Excel file including:

- Carrier(s)

- Policy Number(s)

- Effective/Expiration Date(s)

- Date of Construction/Substantial Improvement*

- Replacement Cost

*Any reconstruction, rehabilitation, additional, or any other improvement of a building, the cost of which equals or exceeds 50 percent of the market value of the building before the start of construction.

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