Submit/Print Documents Payments

Client Login

MAYA - Agent/Broker Of Record Change

Maya Assurance Company
45-18 Court Square, Suite 300, Long Island City, New York 11101
Tel: 718-937 2010 Fax: 718-937 2050

Effective Date

Policy Number

Insured's Name

Policy Effective Date

Policy Expiration Date

Producers Information

First Name *

Last Name *

Street *

City *

State *

ZIP / Postal Code *

Primary Phone Number *

E-Mail Address *

Please be advised that we wish to

Code #

as our exclusive representative effective

(date)

for the policy 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.

Print Insured’s Name

Insured’s Signature

Date

Print Brokers Name

Brokers Code

Brokers Signature

Date

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.

Insurance Websites Designed and Hosted by Insurance Website Builder

Get Directions

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