West Virginia Code of State Rules
Agency 114 - Insurance Commission
Title 114 - LEGISLATIVE RULE INSURANCE COMMISSIONER
Series 114-02 - Licensing And Conduct Of Insurance Producers And Agencies
Appendix 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

_______________________________________________________________________________

Address City State Zip Code

_______________________________________________________________________________

Name of Applicant for Insurance

_______________________________________________________________________________

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