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Online Insurer Corporate Officer Designee Form: Regulation 64 (11 NYCRR216.4)

Complete the following form and click submit to send:
(Mandatory fields are designated by *)


INSURANCE COMPANY NAME *


COMPANY NAIC NUMBER *


CORPORATE CONSUMER SERVICES OFFICER: NAME & TITLE *


ADDRESS 1 *


ADDRESS 2


CITY *


STATE *


ZIP CODE *


DIRECT TELEPHONE NUMBER *


FAX NUMBER *


EMAIL ADDRESS *


COMPLETED BY: NAME AND TITLE *


Will this affect other companies in your group? If so, indicate the company names and NAIC numbers below:


INSURANCE COMPANY NAME


NAIC NUMBER



INSURANCE COMPANY NAME


NAIC NUMBER



INSURANCE COMPANY NAME


NAIC NUMBER


What is the sum of 4 + 5? (spam protection - please answer):

 
  

 

Thank you for using the Online Insurer Corporate Officer Designee Form.

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