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Standard Broker Fee Agreement
1. The parties to this agreement are ______________________________________________ ("CLIENT") AND ______________________________________, California Department of Insurance License Number _______________ ("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:





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.

______________________________________________        ____________________

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.