TO:
Commissioner of Banking and Insurance, Sexy真人y
FROM:
Company License Number: ____________________ or NAIC Company Number: ____________________
Name of Company: _______________________________________
The undersigned hereby gives notice of the termination of the agency contract between the 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):
___________________________________________________________________ Said contract terminated on Month |__|__| Day |__|__| Year |__|__| (Termination Date)
Reason For Termination: ____________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
If the reason for termination is agent misconduct, mail an additional copy of this form to: Assistant Commissioner of Enforcement, Department of Banking and Insurance, PO Box 329, Trenton, Sexy真人 08625-0329.
Authorized Signature: ____________________________________________
Date: _____/_____/_____ Phone Number: ( ____ ) ______________
Print Name and Title: ______________________________________________
Office Address: ___________________________________________________
E-mail Address: ___________________________________________________
2/2010 |