This document is a form for appointing a new servicing agent for an insurance policy or certificate. It contains sections for the policyholder to provide their contact details and signature approving the change. There are also sections for the new servicing agent to provide their details and signature accepting the appointment. The existing agent and quality leader must also sign to agree to the transfer of servicing, commission, or both to the new agent. The policyholder is asked to return the completed form by a specified date so the insurance agency can process the change of servicing agent on the policy.