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Online Insurer Corporate Officer Designee Form: Regulation 64 (11 NYCRR216.4)

Complete 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 company names and NAIC numbers:


 INSURANCE COMPANY NAME


 NAIC NUMBER



 INSURANCE COMPANY NAME


 NAIC NUMBER



 INSURANCE COMPANY NAME


 NAIC NUMBER


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

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Thank you for using the Online Insurer Corporate Officer Designee Form.

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