TO: Commissioner of Banking and Insurance, State of New Jersey

FROM: Company Reference Number: |__|__|__|__|__|__|__|

Name of Company: _______________________________________

The following producer gives notice of the establishment of an agency contract between this company and the insurance producer named below:

Insurance Producer Reference Number - |__|__|__|__|__|__|__|

THIS INFORMATION MAY NOT BE OMITTED

PRINT Name of Insurance Producer (Last, First, Middle):

___________________________________________________________________

Date of Birth: Month |__|__| Day |__|__| Year |__|__|

THIS INFORMATION MAY NOT BE OMITTED IF AN INDIVIDUAL PRODUCER

as its representative in New Jersey commencing Month |__|__| Day |__|__| Year |__|__| (Contract Date) for all types of insurance for which the company and producer are jointly authorized.

I have determined that the insurance producer named holds a current New Jersey insurance license, authorizing transaction of the kinds of insurance covered by this contract.

Authorized Signature: ____________________________________________

Date: _____/_____/_____ Phone Number: ( ____ ) ______________

Print Name and Title: _______________________________________________

Office Address: ___________________________________________________

LP 1/2007