• 631.273.4242


175 Oval Drive



Insurance Company

123 Custom Street


Policy Number: 1001

To Whom It May Concern:

Kindly accept this letter as authorization to recognize the office of National Insurance Brokerage of New York, Inc., 175 Oval Drive, Islandia, New York 11749 as Broker of Record for the above captioned policy effective

The servicing of our account and the collection of premium will be handled by National Insurance Brokerage of NY, Inc. This appointment is made with the understanding that National Insurance Brokerage of NY is not responsible for losses arising out of uninsured areas of our exposure for a period of time sufficient for National Insurance Brokerage of NY to make a review and recommendations concerning our present insurance program and implement the placement of any additional coverages or changes we may authorize.

This letter cancels and supercedes any previous letters of authorization and can only be rescinded in writing by the undersigned.

Please send to the attention of Drew Muller at the above mentioned address a complete copy of our policy along with any open correspondence related to it.

If you should have any questions, please contact at .

Thank you for your immediate attention to this matter.

Very truly yours,

Matilda Dervishaj

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Client Information
Signed by tessssst on Fri Jul 30 2021 15:29:01 GMT+0200 (Central European Summer Time)
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