Call Us 718-805-2211 ☰ ˟
Manage Policy Make a Payment
Logo
718-805-2211
  • Home
  • Broker Change
    • Acord - Agent/Broker Of Record Change
    • ATIC - Voluntary Broker Of Record Change (ATIC 010807)
    • MAYA - Agent/Broker Of Record Change
  • Get A Quote
    • AutomobileImage of right arrow
      • Auto Insurance Quote
      • Auto Quote Form (short)
    • Business & CommercialImage of right arrow
      • Commercial Auto Insurance Quote
      • General Liability Quote Form
      • Business Owners (BOP) Quote Form
      • Builders Risk
      • Workers Compensation Quote
    • Health
    • Homeowners
    • Life
    • Limousine
    • TLC (Taxi)
  • Customer Service
    • Automobile
    • Business & Commercial
    • Health
    • Homeowners
    • Life
    • Limousine
    • TLC (Taxi)
  • Blog
  • Resources
    • Refer a Friend
    • Important Links
    • Insurance Glossary
  • About Us
    • About K.S.BILLING & ASSOC., INC.
    • Location Map
    • Employee Directory
    • Customer Testimonials
    • Privacy Policy
  • Contact
Auto Icon Home Icon Business Icon Life Icon Health Icon Boat Icon
Home > Acord - Agent/Broker Of Record Change
Secured by SSL

Acord - Agent/Broker Of Record Change


New Agency
Phone: 7118-805-2211 Fax: 718-441-3882
K S Billing & Associates, Inc
11812 Atlantic Ave S Richmond Hill, New York 11419-1220
Email Address: tlc@ksbin.com

Date
/ /
Code:
Subcode:
Agency Customer ID:
Insurance Company Name Hereford Insurance Company 36-01 43rd Avenue Long Island City, New York 11101
Current Agency
Current Provider
Name Insured (as it appears on policy)
Policy Number(s)
Effective Date
Expiration Date
Line Of Business
Name Insured (as it appears on policy)
Policy Number(s)
Effective Date
Expiration Date
Line Of Business
Name Insured (as it appears on policy)
Policy Number(s)
Effective Date
Expiration Date
Line Of Business
Name Insured (as it appears on policy)
Policy Number(s)
Effective Date
Expiration Date
Line Of Business
Name Insured (as it appears on policy)
Policy Number(s)
Effective Date
Expiration Date
Line Of Business
Name Insured (as it appears on policy)
Policy Number(s)
Effective Date
Expiration Date
Line Of Business
Please be advised that we wish to name KS BILLING & ASSOCIATES INC (producer) HKSB01(code) as our exclusive representative.
Effective date the form is submitted for the lines of business shown above, currently in force or submitted by application.
This authorization replaces any other authorization that may have been previously completed for any other insurance representative for the stated lines of business.
Insured's Signature
First Name *
Last Name *
Date
/ /
Title (if applicable)
Company Name (if applicable)
Street Address of Insured
Street *
City of Insured
City *
State of Insured: NY
Zip Code of Insured
ZIP / Postal Code *
Primary Phone Number *
E-Mail Address *
ACORD 36 (2007/01)
© ACORD CORPORATION 1996-2007. All rights reserved. The ACORD name and logo are registered marks of ACORD
Submission Validation
Required

Important Notice
Any submissions or payments made via this website do not constitute a binding agreement to your policy or coverages. Changes and payments to policies are not effective or binding until you, or any party involved, receive official notice from either your insurance agent, or your insurance company. If you have any questions, please feel free to contact us.

Per the terms of our online privacy policy we will not resell your information to any third-party.
Secured by SSL
Insurance Websites Designed and Hosted by Insurance Website Builder
Facebook
Twitter
Google+
LinkedIn
Get Directions
Contact Us Today
Speak to an agent!
Resources
Products
Make A Payment
Report a Claim
Our Carriers
About Us
Refer A Friend
Blog
Contact Us
Contact us 119-22 94th Ave
South Richmond Hill, NY 11419
718-441-3882
insurance@ksbin.com
© Copyright. All rights reserved. Powered by Insurance Website Builder.