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ATIC - Voluntary Broker Of Record Change (ATIC 010807)

Fill out the following form as completely as possible. Once you have completed the form, click the Submit button to send your information. Your request will be handled promptly.

Producer

Insurance Company Name

American Transit Insurance Company, Inc (036) 330 West 34th. Street New York, NY 10001

Code

Policy Number

Insured

Med/Plate #

Effective Date

Expiration Date

Statement Of Insured

First Name *

Last Name *

, hereby request American Transit Insurance Company, Inc. to recognize my new Producer of record

(producer of record name)

effective as of

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

Date

Producer's Signature

Date

ZIP / Postal Code *

Primary Phone Number *

E-Mail Address *

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.

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