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PERSONAL INLAND MARINE APPLICATION

carrier naic code plan facility code fax (a/c, no): agency name: contact (a/c, no, ext): phone code: subcode: ... semi-annual annual full pay payment plan mail policy to: agent insured agency bill ... statement of claim or an application containing any false, incomplete, or misleading information is …

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Statutory page 14) in the NAIC P/C annual statement. In the Workers’ Compensation and Total All Lines sections of this report, Direct Written Premiums includes year priorstate fund premium data reported - directly to the NAIC for the following states: North Dakota, Ohio, South Carolina, Washington and Wyoming.

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COMMERCIAL INSURANCE APPLICATION DATE …

myagency.amwinsadmittedplacement.com

statement of claim containing any materially false information, or conceals for the purpose of misleading information concerning any FACT MATERIAL THERETO, COMMITS A FRAUDULENT INSURANCE ACT, WHICH IS A CRIME AND SUBJECTS THE PERSON TO CRIMINAL AND [NY: SUBSTANTIAL] CIVIL

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Applicant Company Name: NAIC No.: FEIN:

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Yes No If the answer to any of the above is yes, please indicate and give details. When responding to questions (b) and (c), affiant should also include any events within twelve (12) months after his or her departure from the entity.

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Market Share, NAIC, Annual statement, NAIC Annual, Statement, UCAA Primary Application, OSIRIS - Data Guide, Annual, Insurance Accounting and Financial Reporting Update, COMMERCIAL INSURANCE APPLICATION DATE