ACORD 808 (2009/03) rev. 04-17-2009 1 of 6
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Section Name |
Field Name |
Field and/or Section Description |
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TITLE ACORD 808 (2009/03) |
P & C Agency Appointment Form |
The title of the form. ACORD 808, P & C Agency Appointment Form, is a standard Agency Appointment Form designed for P & C / Surety appointments and accepted by multiple insurers. In this case, the agency is an organization. This form is to be completed by a Producer and then sent to the insurer. ACORD 808 is comprised of the data content needed for new PCS agency appointments. |
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IDENTIFICATION SECTION |
Date |
Enter date: The month/day/year on which the form is completed. (MM/DD/YYYY) |
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IDENTIFICATION SECTION |
Carrier Name |
Enter text: The insurer's full legal company name(s) as found in the file copy of the policy. Use the actual name of the company within the group to which the policy has been issued. This is not the insurer's group name or trade name. |
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IDENTIFICATION SECTION |
NAIC Code |
Enter code: The identification code assigned to the insurer by the NAIC. |
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AGENCY INFORMATION |
Agency Full Legal Name |
Enter text: The full name of the producer/agency. As used here, this is the full name of the agency at which the producer (person) is employed with regards to this appointment request. |
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AGENCY INFORMATION |
Agency Address |
Enter text: The mailing address line one of the producer/agency. |
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AGENCY INFORMATION |
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Enter text: The mailing address line two of the producer/agency. |
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AGENCY INFORMATION |
City |
Enter text: The mailing address city name of the producer/agency. |
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AGENCY INFORMATION |
State |
Enter code: The mailing address state or province code of the producer/agency. |
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AGENCY INFORMATION |
Zip |
Enter code: The mailing address postal code of the producer/agency. |
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AGENCY INFORMATION |
Agency DBA |
Enter text: The name by which an organization is doing business. |
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AGENCY INFORMATION |
FEIN |
Enter identifier: The producer's tax identification number. This may be the federal employer identification number or social security number. As used here, this is the FEIN for the agency. |
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AGENCY INFORMATION |
Licensing Contact |
Enter text: The name of the individual at the producer's establishment that is the primary contact. As used here, this is the name of the licensing contact person within the agency. Contact this person if there are any questions about the appointment form. |
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AGENCY INFORMATION |
Contact Phone |
Enter number: The producer's contact person's phone number. If applicable, include the area code and extension. |
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AGENCY INFORMATION |
Contact Fax |
Enter number: The producer's contact person's fax number. |
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AGENCY INFORMATION |
Contact Email |
Enter text: The producer's contact person e-mail address. |
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AGENCY INFORMATION |
Agency Website |
Enter text: The website address for the producer / agency. |
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AGENCY INFORMATION |
Legal Entity Type - Sole Proprietor |
Check the box (if applicable): Indicates the legal entity code for the producer is "Sole Proprietor". |
ACORD 808 (2009/03) rev. 04-17-2009 2 of 6
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Section Name |
Field Name |
Field and/or Section Description |
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Check the box (if applicable): Indicates the legal entity code for the producer is |
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AGENCY INFORMATION |
Legal Entity Type - Corporation |
"Corporation". |
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Check the box (if applicable): Indicates the legal entity code for the producer is |
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AGENCY INFORMATION |
Legal Entity Type - Partnership |
"Partnership". |
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Legal Entity Type - Limited |
Check the box (if applicable): Indicates the legal entity code for the producer is "Limited |
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AGENCY INFORMATION |
Liability Company (LLC) |
Liability Company". |
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Legal Entity Type - Limited |
Check the box (if applicable): Indicates the legal entity code for the producer is "Limited |
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AGENCY INFORMATION |
Liability Partnership (LLP) |
Liability Partnership". |
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MAILING ADDRESS |
Street Address |
Enter text: The mailing address line one of the producer/agency. |
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MAILING ADDRESS |
City |
Enter text: The mailing address city name of the producer/agency. |
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MAILING ADDRESS |
State |
Enter code: The mailing address state or province code of the producer/agency. |
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MAILING ADDRESS |
Zip |
Enter code: The mailing address postal code of the producer/agency. |
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Check the box (if applicable): Indicate the appointment or termination applies in the state |
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STATES AND US |
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or territory. As used here, indicates that the appointment or termination applies to all |
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TERRITORIES |
All States |
states. |
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STATES AND US |
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Check the box (if applicable): Indicate the appointment or termination applies in the state |
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TERRITORIES |
AK - Alaska |
or territory. |
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STATES AND US |
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Check the box (if applicable): Indicate the appointment or termination applies in the state |
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TERRITORIES |
AL - Alabama |
or territory. |
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STATES AND US |
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Check the box (if applicable): Indicate the appointment or termination applies in the state |
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TERRITORIES |
AR - Arkansas |
or territory. |
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STATES AND US |
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Check the box (if applicable): Indicate the appointment or termination applies in the state |
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TERRITORIES |
AZ - Arizona |
or territory. |
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STATES AND US |
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Check the box (if applicable): Indicate the appointment or termination applies in the state |
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TERRITORIES |
CA - California |
or territory. |
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STATES AND US |
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Check the box (if applicable): Indicate the appointment or termination applies in the state |
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TERRITORIES |
CO - Colorado |
or territory. |
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STATES AND US |
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Check the box (if applicable): Indicate the appointment or termination applies in the state |
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TERRITORIES |
CT - Connecticut |
or territory. |
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STATES AND US |
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Check the box (if applicable): Indicate the appointment or termination applies in the state |
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TERRITORIES |
DC - District of Columbia |
or territory. |
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STATES AND US |
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Check the box (if applicable): Indicate the appointment or termination applies in the state |
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TERRITORIES |
DE - Delaware |
or territory. |
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STATES AND US |
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Check the box (if applicable): Indicate the appointment or termination applies in the state |
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TERRITORIES |
FL - Florida |
or territory. |
ACORD 808 (2009/03) rev. 04-17-2009 3 of 6
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Section Name |
Field Name |
Field and/or Section Description |
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STATES AND US TERRITORIES |
GA - Georgia |
Check the box (if applicable): Indicate the appointment or termination applies in the state or territory. |
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STATES AND US TERRITORIES |
HI - Hawaii |
Check the box (if applicable): Indicate the appointment or termination applies in the state or territory. |
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STATES AND US TERRITORIES |
IA - Iowa |
Check the box (if applicable): Indicate the appointment or termination applies in the state or territory. |
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STATES AND US TERRITORIES |
ID - Idaho |
Check the box (if applicable): Indicate the appointment or termination applies in the state or territory. |
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STATES AND US TERRITORIES |
IL - Illinois |
Check the box (if applicable): Indicate the appointment or termination applies in the state or territory. |
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STATES AND US TERRITORIES |
IN - Indiana |
Check the box (if applicable): Indicate the appointment or termination applies in the state or territory. |
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STATES AND US TERRITORIES |
KS - Kansas |
Check the box (if applicable): Indicate the appointment or termination applies in the state or territory. |
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STATES AND US TERRITORIES |
KY - Kentucky |
Check the box (if applicable): Indicate the appointment or termination applies in the state or territory. |
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STATES AND US TERRITORIES |
LA - Louisiana |
Check the box (if applicable): Indicate the appointment or termination applies in the state or territory. |
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STATES AND US TERRITORIES |
MA - Massachusetts |
Check the box (if applicable): Indicate the appointment or termination applies in the state or territory. |
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STATES AND US TERRITORIES |
MD - Maryland |
Check the box (if applicable): Indicate the appointment or termination applies in the state or territory. |
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STATES AND US TERRITORIES |
ME - Maine |
Check the box (if applicable): Indicate the appointment or termination applies in the state or territory. |
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STATES AND US TERRITORIES |
MI - Michigan |
Check the box (if applicable): Indicate the appointment or termination applies in the state or territory. |
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STATES AND US TERRITORIES |
MN - Minnesota |
Check the box (if applicable): Indicate the appointment or termination applies in the state or territory. |
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STATES AND US TERRITORIES |
MO - Missouri |
Check the box (if applicable): Indicate the appointment or termination applies in the state or territory. |
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STATES AND US TERRITORIES |
MS - Mississippi |
Check the box (if applicable): Indicate the appointment or termination applies in the state or territory. |
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STATES AND US TERRITORIES |
MT - Montana |
Check the box (if applicable): Indicate the appointment or termination applies in the state or territory. |
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STATES AND US TERRITORIES |
NC - North Carolina |
Check the box (if applicable): Indicate the appointment or termination applies in the state or territory. |
ACORD 808 (2009/03) rev. 04-17-2009 4 of 6
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Section Name |
Field Name |
Field and/or Section Description |
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STATES AND US TERRITORIES |
ND - North Dakota |
Check the box (if applicable): Indicate the appointment or termination applies in the state or territory. |
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STATES AND US TERRITORIES |
NE - Nebraska |
Check the box (if applicable): Indicate the appointment or termination applies in the state or territory. |
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STATES AND US TERRITORIES |
NH - New Hampshire |
Check the box (if applicable): Indicate the appointment or termination applies in the state or territory. |
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STATES AND US TERRITORIES |
NJ - New Jersey |
Check the box (if applicable): Indicate the appointment or termination applies in the state or territory. |
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STATES AND US TERRITORIES |
NM - New Mexico |
Check the box (if applicable): Indicate the appointment or termination applies in the state or territory. |
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STATES AND US TERRITORIES |
NV - Nevada |
Check the box (if applicable): Indicate the appointment or termination applies in the state or territory. |
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STATES AND US TERRITORIES |
NY - New York |
Check the box (if applicable): Indicate the appointment or termination applies in the state or territory. |
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STATES AND US TERRITORIES |
OH - Ohio |
Check the box (if applicable): Indicate the appointment or termination applies in the state or territory. |
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STATES AND US TERRITORIES |
OK - Oklahoma |
Check the box (if applicable): Indicate the appointment or termination applies in the state or territory. |
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STATES AND US TERRITORIES |
OR - Oregon |
Check the box (if applicable): Indicate the appointment or termination applies in the state or territory. |
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STATES AND US TERRITORIES |
PA - Pennsylvania |
Check the box (if applicable): Indicate the appointment or termination applies in the state or territory. |
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STATES AND US TERRITORIES |
RI - Rhode Island |
Check the box (if applicable): Indicate the appointment or termination applies in the state or territory. |
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STATES AND US TERRITORIES |
SC - South Carolina |
Check the box (if applicable): Indicate the appointment or termination applies in the state or territory. |
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STATES AND US TERRITORIES |
SD - South Dakota |
Check the box (if applicable): Indicate the appointment or termination applies in the state or territory. |
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STATES AND US TERRITORIES |
TN - Tennessee |
Check the box (if applicable): Indicate the appointment or termination applies in the state or territory. |
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STATES AND US TERRITORIES |
TX - Texas |
Check the box (if applicable): Indicate the appointment or termination applies in the state or territory. |
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STATES AND US TERRITORIES |
UT - Utah |
Check the box (if applicable): Indicate the appointment or termination applies in the state or territory. |
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STATES AND US TERRITORIES |
VA - Virginia |
Check the box (if applicable): Indicate the appointment or termination applies in the state or territory. |
ACORD 808 (2009/03) rev. 04-17-2009 5 of 6
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Section Name |
Field Name |
Field and/or Section Description |
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STATES AND US |
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Check the box (if applicable): Indicate the appointment or termination applies in the state |
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TERRITORIES |
VT - Vermont |
or territory. |
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STATES AND US |
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Check the box (if applicable): Indicate the appointment or termination applies in the state |
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TERRITORIES |
WA - Washington |
or territory. |
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STATES AND US |
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Check the box (if applicable): Indicate the appointment or termination applies in the state |
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TERRITORIES |
WI - Wisconsin |
or territory. |
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STATES AND US |
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Check the box (if applicable): Indicate the appointment or termination applies in the state |
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TERRITORIES |
WV - West Virginia |
or territory. |
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STATES AND US |
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Check the box (if applicable): Indicate the appointment or termination applies in the state |
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TERRITORIES |
WY - Wyoming |
or territory. |
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Check the box (if applicable): Indicate the appointment or termination applies in the state |
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STATES AND US |
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or territory. As used here, indicates that the appointment or termination applies to all |
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TERRITORIES |
All Territories |
territories. |
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STATES AND US |
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Check the box (if applicable): Indicate the appointment or termination applies in the state |
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TERRITORIES |
AS - American Samoa |
or territory. |
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STATES AND US |
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Check the box (if applicable): Indicate the appointment or termination applies in the state |
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TERRITORIES |
GU - Guam |
or territory. |
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STATES AND US |
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Check the box (if applicable): Indicate the appointment or termination applies in the state |
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TERRITORIES |
PR - Puerto Rico |
or territory. |
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STATES AND US |
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Check the box (if applicable): Indicate the appointment or termination applies in the state |
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TERRITORIES |
VI - Virgin Islands |
or territory. |
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Other Information |
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STATES AND US TERRITORIES |
Does your agency operate under another license and / or name in any other state? |
Enter Y for a “Yes” response. Input N for “No” response. Indicates the response to the question, "Does your agency operate under another license and / or name in any other state?". |
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STATES AND US |
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TERRITORIES |
Name |
Enter text: The full name of the agency. |
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STATES AND US |
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TERRITORIES |
State |
Enter code: The state or province code in which the agency is located. |
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STATES AND US |
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TERRITORIES |
Name |
Enter text: The full name of the agency. |
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STATES AND US |
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TERRITORIES |
State |
Enter code: The state or province code in which the agency is located. |
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STATES AND US |
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TERRITORIES |
Name |
Enter text: The full name of the agency. |
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Section Name |
Field Name |
Field and/or Section Description |
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STATES AND US TERRITORIES |
State |
Enter code: The state or province code in which the agency is located. |
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STATES AND US TERRITORIES |
Name |
Enter text: The full name of the agency. |
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STATES AND US TERRITORIES |
State |
Enter code: The state or province code in which the agency is located. |
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CARRIER ADDRESS |
Street Address |
Enter text: The first line of the insurer's mailing address. |
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CARRIER ADDRESS |
City |
Enter text: The city of the insurer's mailing address. |
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CARRIER ADDRESS |
State |
Enter code: The state or province of the insurer's mailing address. |
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CARRIER ADDRESS |
Zip |
Enter code: The postal code of the insurer's mailing address. |
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SIGNATURES |
Agency Representative Name |
Enter text: The name of the authorized representative of the producer, agency and/or broker that signed the form. |
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SIGNATURES |
Signature |
Sign here: Accommodates the signature of the authorized representative (e.g. producer, agent, broker, etc.). by all companies to issue Certificates. This is required in most states. |
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SIGNATURES |
Date |
Enter date: The date the producer signed the form. |
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Edition |
Date |
The edition identifier of the form including the form number and edition (the date is typically formatted YYYY/MM). |