225 International Circle
Box 8016
Hunt Valley, MD  21030

Subject:  Broker of Record Letter

Medical Mutual Professional Liability Policy
Policy Number:   ____________________________________
MedGuard Policy Number:  ___________________________

To Whom It May Concern:

I, the undersigned, herewith name the Med Chi Insurance Agency, 1204 Maryland Avenue, Baltimore, MD 21201 as my Broker of Record for the placement and service of my Medical Professional Liability Insurance. 

This supersedes all previous appointments and shall remain in full force and effect until canceled by me.  I request that all future transactions be handled by the Med Chi Insurance Agency and that they be provided with any policy detail requested.


Policy Name:__________________________________________________________________


Phone Number:________________________________________________________________

Email Address:________________________________________________________________



          ____________________________________________  ____________________
                                           Policy Holder                                                   Date

          ____________________________________________  ____________________
                                             Print Name                                                  Policy #

          ____________________________________________  ____________________
                                        Broker Signature                                                Date


Please sign and return to The Med Chi Insurance Agency, Inc. - Via fax 410.649.4154

1204 Maryland Avenue, Baltimore, MD 21201 / 410.539.6642 / TOLL FREE: 800.543.1262 / FAX: 410-752-5421