State of New Jersey
Department of Banking and Insurance
License Processing
PO Box 327
Trenton, New Jersey 08625-0327
Branch Office Registration
Fee information: Processing Fee $20.00 x Branch Offices ______ = Total Fees $___________

Attach one check for the total fees as calculated above, and make the check payable to:
"State of New Jersey, General Treasury"

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

FROM: Producer _______________________________________________________

Reference Number: |__|__|__|__|__|__|__|

Enter the required information for each new branch office in the space provided.

Room |__|__|__|__|__| Suite |__|__|__|__|__| Apt |__|__|__|__|__|

Street Address: |__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|

PO Box: |__|__|__|__|__|__|
Note: You must supply a street or location address; a PO Box alone is not sufficient. The City, State and ZIP Code must reflect the location of the PO Box.

City: |__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__| State: |_N_|_J_|

ZIP Code: |__|__|__|__|__|-|__|__|__|__| County: |__|__|__|__|__|__|__|__|__|__|__|

Each branch office will be operated in accordance with N.J.A.C. 11:17-2.9. It will be open for sufficient hours and days of the week to provide the public with reasonable access. The hours will be posted. It will be staffed by at least one licensed producer whenever the office is engaged in insurance related conduct requiring licensure.

Signature: ______________________________________________________ Date: ___/___/___

Signature of Designated Responsible Licensed Producer; officer; or owner of 10% or more of the business entity named above

LP 1/2007