Date

CARRIER NAME:

Re: Group Name

GROUP #

 

To Whom It May Concern:

This is to advise you that effective immediately, the servicing Agent of record on the above captioned policy be changed to __________________
at Oberlander & Dorfman, Inc. located at 700 Merrick Road, Lynbrook, New York 11563.

Thank you for your anticipated cooperation in this matter.

Sincerely,

________________, President