Cal. Code Regs. Tit. 10, ch. 5, subch. 1, art. 6.8, app B
1. The parties to this agreement are _______________ ("CLIENT") and ____________________, California Department of Insurance license #XXXXXXX, ("BROKER").
2. CLIENT appoints BROKER as CLIENT'S insurance broker of record.
3. This agreement shall become operative on _______________ (date), and shall continue in full force until terminated by either party.
4. BROKER agrees to represent CLIENT honestly and competently.
5. CLIENT agrees to pay BROKER a broker fee for BROKER'S services. The broker fee is $_____. The broker fee IS / IS NOT refundable (circle one).
6. BROKER may in the future charge CLIENT, and CLIENT agrees to pay, additional fee(s) for the services listed below. The additional fees and services are:
| Service | Amount |
7. Following are the nature and amount of all fees known to BROKER that will be charged by persons other than BROKER or the insurance company in connection with current placement of CLIENT's insurance. These fees are not retained by BROKER.
| Service | Amount |
| ___________________________ | ||
| Client signature | Date | |
| ___________________________ | ||
| Broker signature | Date | |
In case of any questions or problems concerning broker fees or insurance, contact the Department of Insurance at 1-(800) 927-HELP.
#10222 v1 - BROKER FEE REGS - AGREEMENT FORM AS OF 3-21-00
March 22, 2000
Cal. Code Regs. Tit. 10, ch. 5, subch. 1, art. 6.8, app B