|State of New Jersey
Department of Banking and Insurance
P.O. Box 327
Trenton, New Jersey 08625-0327
|Notice of Reinsurance Intermediary Manager|
TO: Commissioner of Banking and Insurance, State of New Jersey
Name Of Company: _______________________________________
PRINT Name of Insurance Producer (Last, First, Middle):
Date of Birth: Month |__|__| Day |__|__| Year |__|__|
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: _______________________________________________
Office Address: ____________________________________________________
Attach a copy of the contract between the company and the reinsurance intermediary-manager.