Acord - Agent/Broker Of Record Change
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: email@example.com
Insurance Company Name Hereford Insurance Company 36-01 43rd Avenue Long Island City, New York 11101
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.
Street Address of Insured
City of Insured
State of Insured: NY
Zip Code of Insured
ACORD 36 (2007/01)
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