This letter appoints Retail Insurance Name and Robert Itzinger of R-T Specialty Insurance Service as the sole and exclusive agent/broker of record for the insured. It rescinds any previous appointments and authorizes direct negotiation with Retail Insurance Name and Robert Itzinger regarding existing policies, changes, cancellations, and temporary binders. The letter also authorizes Retail Insurance Name and Robert Itzinger to request and receive any insurance-related information to study the insured's current and future requirements, and requests the carrier not share this information with anyone else.

1. Please reproduce this letter on Insured’s letterhead
Date
Carrier:
c/o R-T SPECIALTY INSURANCESERVICE, LLC
Re: Coverage:
Effective:
Dear Sirs:
We hereby appoint Retail Insurance Name and Robert Itzinger at R-T SPECIALTY
INSURANCE SERVICE, LLC as our Sole Agent/Broker of Record to act as our
EXCLUSIVErepresentative on insurance matters,and as provided in Insurance
Code Section 770.1. This appointment of Retail Insurance Name and Robert
Itzinger at R-T SPECIALTY INSURANCE SERVICE, LLC rescinds any and all
previous appointments and the authority contained herein shall be irrevocable.
This waives any and all waiting periods.
This letter constitutes your authority to negotiate directlywith representatives of
Retail Insurance Name and Robert Itzinger at R-T SPECIALTY INSURANCE
SERVICE, LLC with respects to existing insurance policies and in closing,
changing or cancellation insurance carried under temporary binder or cover
notes. We understand,however,that Retail Insurance Name and Robert Itzinger
at R-T SPECIALTY INSURANCESERVICE, LLC will not share responsibility for
any deficienciesin the insurance program to whichthis letter applies until they
have had a reasonable opportunity to make a review and we have accepted their
recommendations.
This letter also constitutes your authority to furnish the representative Retail
Insurance Name and Robert Itzinger at R-T SPECIALTY INSURANCE SERVICE,
LLC with all information they may request as it pertains to our insurance
contracts,rates, rating schedules, surveys, reserves, retentions and all other
financial data they may wish to obtain for their study of our present and future
requirements in connection with the insurance program to which this letter
applies. We request that you do not communicate such information to anyone
else.
Sincerely,
Print Name / Title
Signature
Date