TO:
Commissioner of Banking and Insurance, State of New Jersey

FROM:
Company License Number: ____________________ or NAIC Company Number: ____________________

Name of Company: _______________________________________

The following producer gives notice of the establishment of an agency contract between this company and the insurance producer named below:

Producer License Number: ___________________ or National Producer Number: ___________________

THIS INFORMATION MAY NOT BE OMITTED

PRINT Name of Insurance Producer (Last, First, Middle or Agency Name):

___________________________________________________________________

Date of Birth: Month |__|__| Day |__|__| Year |__|__|

DATE OF BIRTH REQUIRED FOR INDIVIDUAL PRODUCER

as its representative in New Jersey commencing Month |__|__| Day |__|__| Year |__|__| (Contract Date) for all types of insurance for which the company and producer are jointly authorized.

I have determined that the insurance producer named holds a current New Jersey insurance license, authorizing transaction of the kinds of insurance covered by this contract.

Authorized Signature: ____________________________________________

Date: _____/_____/_____ Phone Number: ( ____ ) ______________

Print Name and Title: _______________________________________________

Office Address: ___________________________________________________

E-mail Address: ___________________________________________________

2/2010