Reg 64: Insurer Corporate Designee Form

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The Department requires each insurer to designate one individual per insurer as corporate officer responsible for its internal consumer services department.

Use this form to submit, confirm or update the existing information in our records as stipulated in Circular Letter No. 14.

The Department must be informed immediately whenever there is a change in any of the information on file with DFS.

Insurance Company Name

NAIC Number

Corporate Consumer Services Officer

Address

Address 2

City/Town

State/Province

ZIP/Postal Code

Country

Direct Phone Number

Fax Number

Email address

Completed By

Email Address for Routine Correspondence

This can be a general email address or shared mailbox and is the address where you'd like us to send daily correspondence.

General Phone Number

This should be the general phone number that we (DFS) will use to follow up on correspondence with you.

Additional Company Name

NAIC Number

Additional Company Name

NAIC Number

Additional Company Name

NAIC Number

Reg 64: Insurer Corporate Designee Form

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