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

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

Name Of Company: _______________________________________

The undersigned hereby gives notice of the termination of the agency contract btween the 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):

___________________________________________________________________

Said contract terminated on Month |__|__| Day |__|__| Year |__|__| (Termination Date)

Reason For Termination: ____________________________________________________________

_________________________________________________________________________________

_________________________________________________________________________________

If the reason for termination is agent misconduct, mail an additional copy of this form to: Assistant Commissioner of Enforcement, Department of Banking and Insurance, P.O. Box 329, Trenton, NJ 08625-0329.

Authorized Signature: ____________________________________________

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

Print Name and Title: ______________________________________________

Office Address: ___________________________________________________

LP 1/2007