Broker Transfer Release Form Please complete the form below. 1. BROKER/AGENCY REQUESTING TRANSFER Signature: _____________________________________________
Date: _____________________
Printed Name: _________________________________________
NPN: _____________________
2. CURRENT UPLINE PROVIDING THE TRANSFER RELEASE Signature: _____________________________________________
Date*:____________________
Printed Name: __________________________________________ GA/FMO/Agency: ________________________________________ 3. NEWLY SELECTED GA/FMO/AGENCY Signature: _____________________________________________
Date: _____________________
Printed Name: __________________________________________ Agency Name (please print): _______________________________
Please fax or scan your completed document to: Email:
[email protected] Fax: 216-479-5555
*Effective date of the transfer is 30 days after the signature date for the next commission cycle
Modified: July 2015