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.