W. Va. Code R. agency 114, tit. 114, ser. 114-02, app A
Producer Company Relationship Disclosure
Non-Appointed Producer
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Name of Producer West Virginia Producer Number
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Name of Agency, Company or Firm West Virginia Agency Producer Number
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Address City State Zip Code
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Name of Applicant for Insurance
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Address City State Zip Code
I, the above named applicant, have been advised by the above named individual insurance producer that he or she is not appointed with the insurer to which my application is being submitted, and the above named producer will be placing my application for insurance through an appointed producer. The above named producer has disclosed to me that he or she is not authorized to bind coverage or to execute or issue a policy on the company's behalf.
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Signature of Applicant Date
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Signature of Individual Insurance Producer Date
W. Va. Code R. agency 114, tit. 114, ser. 114-02, app A