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Home > Acord - Agent/Broker Of Record Change
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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.

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Contact us 119-22 94th Ave
South Richmond Hill, NY 11419
718-441-3882
insurance@ksbin.com
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