__/__/2005

Re: Carrier: ___________________________ Policy #:__________________

Re: Carrier: ___________________________ Policy #:__________________

To whom it may concern:

Our organization/business is insured with your company under the group policy/policies listed above. Effective immediately I wish to appoint the following agent and insurance company as our agent of record:

Stepping Stone Insurance Services/PLH Insurance Agency
License # 0E05656
2272 Colorado Blvd. #1165
Los Angeles CA 90041
(866) 420-4606 Toll Free Phone - (310) 734-1796 Fax

Please correct your records to indicate this appointment and send Stepping Stone Insurance Services written confirmation when completed.

Thank you for your attention to this matter. If you have any questions, please do not hesitate to call or email US.

Sincerely,

Phone Number:______________

E-mail Address:______________