49.9 kb ) for free. This is to notify you that i have appointed (broker name) of (agency name) whose business address is ( street address, city, state and zip) as my broker of record with respect to coverage provided by guardian. Insurance policies listed by policy #, insurance company, effective dates, and type of insurance. We also understand that [name of roker agency]’s broker commission will be paid out of our monthly premiums. A broker of record letter can be used to designate a broker of record for the first time or to replace an existing broker of record with a.