DISRsiucp

DC POINT OF CONTACT PERSONS FORM

Fields marked with an asterisk ( * ) are required.

Insurer/HMO:*

Group reporting − If you need additional space, please submit a separate sheet in Word format to:

Representing Underwriting Companies:

NAIC Number:*

Group Number:*

if none enter "0"

A−Compliance Contact Person:*

Title/Position:*

Mailing Address:*

City:*

State:*

Zip:*

Phone:*

Fax:

Email:*

B−SIU Contact Person

(if differ from A−Compliance):

Title/Position:

Mailing Address:

City:

State:

Zip:

Phone:

Fax:

Email: