Date: 

Authorization of Acuity Risk Consultants, Inc. 

To whom it may concern: 

I, ___________________________ Owner and Operator of _________________________________ authorize Acuity Risk Consultants, Inc. and its representatives to act on our behalf with respects to all current, past insurances, including but not limited to quotes, policies, exposures, loss history, marketing summaries, summaries of insurance, premium history and other relevant insurance related materials deemed necessary. Effective immediately please refer all matters to Acuity Risk Consultants, Inc.

Thank you.