Transcription of AGENT/BROKER OF RECORD CHANGE - nstarco.com
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AGENT/BROKER OF RECORD CHANGE - nstarco.com
(A/C, No, Ext):PHONE(A/C, No):FAXNEW AGENCYSUBCODE:CODE: agency customer ID:E-MAILADDRESS: ACORD CORPORATION 1996-2007. All rights ACORD name and logo are registered marks of ACORDACORD 36 (2007/01)CURRENT PRODUCERCURRENT AGENCYINSURANCE COMPANY NAMESTATE OF INSUREDZIP CODE OF INSUREDCITY OF INSUREDSTREET ADDRESS OF INSUREDTITLE (IF APPLICABLE)COMPANY NAME (IF APPLICABLE)stated lines of completed for any other insurance representative for theThis authorization replaces any other authorization that may have beenDATEINSURED'S SIGNATUREDATECODE #PRODUCERby the lines of business shown above, currently in force or submittedas our exclusive representative effectivePlease be advised that we wish to nameNAMED INSURED(AS IT APPEARS ON POLICY)
(a/c, no, ext): phone (a/c, no): fax new agency code: subcode: agency customer id: e-mail address: © acord corporation 1996-2007. all rights reserved.
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