Brokerage Agreement

(Name of Client) (“Client”) hereby designates Historic Square Agency to act as your exclusive representative in the marketplace to locate insurance for Client’s insurance needs. Acting as your representative, Producer will provide Client various services during this process as described below:

• Discuss with you specifics about your insurance needs;
• Assist you, at your request, with completion of any application for insurance;
• Search available markets for an insurer(s) interested in providing insurance;
• Present to you any proposals and/or sample policies or policy summaries of insurers willing to provide a quote offer;
• Facilitate the acceptance process; binder issuance and policy delivery;
• Assist you throughout the policy term by providing assistance and service on the policy as reasonably expected;
• Facilitate claims handling.

Our agency as Producer does not charge a fee for services as Client’s representative in the marketplace. However, in addition to the policy premium, certain fees may be charged by the insurer, general agency, the state or other party(s) in the process. Any such fees will be disclosed at the time a quote/proposal offer is made and can include such items as:

• Policy fee
• Administrative fee
• Insurer fee
• Surplus lines tax
• Surplus lines stamping fee

Client agrees that such fees may be charged and agrees to pay such fees, in addition to the premium, as a condition to coverage and will timely remit such payment when billed. All premium and fees will be disclosed as part of the quote/offer and shall be in writing. Acceptance by Client of the quote/offer constitutes Client’s awareness and acceptance of such fee(s) charges. This Agreement shall apply to renewal of any policy issued as the result of the Agreement but may be revoked by either Client or Producer to be effective at the next annual anniversary date of the policy.

By Producer		By Client
Date:		Date: