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 Reisnurance Intermediary in New Jersey commencing Month |__|__| Day |__|__| Year |__|__| (Contract Date) for all types of insurance for which the company and producer are jointly authorized. The above reinsurance intermediary-manager producer has filed with this company a bond and Errors and Omissions ("E and O") policy in accordance with NJAC 11:17-7

I have determined that the reinsurance intermediary-manager named holds a current New Jersey insurance license, authorizing transaction of the kinds of insurance covered by this contract. We understand that the bond and E and O policy must be updated yearly.

Authorized Signature: _______________________________________________

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

Print Name and Title: _______________________________________________

Office Address: ____________________________________________________

Attach a copy of the contract between the company and the reinsurance intermediary-manager.

DHTREG.2/LRWPC/m/1
LP 1/2007