New York Information Network (NYIN)

Primary & Secondary Intelligence/Information Officers Designation Form

Pursuant to Circular Letter No. 12 (2002), please complete all fields in the form below to enter your company's Designated Primary and Secondary Intelligence / Information Officers data in the New York Information Network (NYIN).

Use this form for both original or update data entry. Mandatory Fields are indicated with *.

I) Company Information

   NAIC No*:
   If your company does not have an NAIC # assigned, please enter 00000

   Name of Insurer*:

   Insurer Type*:

   Address 1*:

   Address 2:

   City*:

   State*:

    Zip*:

   Country*:

II) Company CEO Information

    CEO Last Name*:

    CEO First Name*:

    CEO Middle Initial:

    CEO Phone No.*: ()

    CEO E-Mail Address*:

    Verify CEO E-Mail Address*:

III) Primary Intelligence/Information Officer

     Last Name*:

     First Name*:

     Middle Initial:

     Title*:

     Work Phone No.*: ()

     Extension:

    Fax No.*: ()

     Pager No.: ()

     1st E-Mail Address*:

     Verify E-Mail Address*:

     Backup E-Mail Address:

IV)Secondary Intelligence/Information Officer:

    Last Name*:

    First Name*:

    Middle Initial:

    Title*:

    Work Phone No.*: ()

    Extension:

    Fax No.*: ()

    Pager No.: ()

    1st E-Mail Address*:

    Verify E-Mail Address*:

    Backup E-Mail Address:

What is the sum of 3 + 5? (spam protection - please answer):

Select 'Submit Form' to transmit. To clear all fields, select 'Reset Form'.

After submitting this e-form, you will be re-directed to the NYIN Home Page and receive a confirmation e-mail from the Department.