Letter of Authority

Please complete this form to grant Feldwick Insurance Brokers permission to contact your current insurer(s) and request information needed to advise or provide you with quotes.

Your Details

Insured Entity or Entities Name(s) *

Email Address *

Phone Number (Optional)

Insurance Information

Current Insurer Name *

Policy Number(s) (Optional)

Renewal Date (Optional)

Declaration and Signature

I authorise Feldwick Insurance Brokers to act on my behalf in obtaining information about my existing insurance policies from the insurer(s) listed above. I understand that this authority allows Feldwick to request policy schedules, renewal dates, terms of cover, and claims history to assist in providing me with insurance advice or quotes.

I agree to the terms above

Digital Signature *

Date of submission will be automatically recorded.