TO:
Commissioner of Banking and Insurance, State of New Jersey

FROM:
Company License Number: ____________________ or NAIC Company Number: ____________________

Name of Company: _______________________________________

The undersigned hereby gives notice of the termination of the agency contract between the company and the insurance producer named below:

Producer License Number: ___________________ or National Producer Number: ___________________

THIS INFORMATION MAY NOT BE OMITTED

PRINT Name of Insurance Producer (Last, First, Middle or Agency Name):

___________________________________________________________________

Said contract terminated on Month |__|__| Day |__|__| Year |__|__| (Termination Date)

Reason For Termination: ____________________________________________________________

_________________________________________________________________________________

_________________________________________________________________________________

If the reason for termination is agent misconduct, mail an additional copy of this form to: Assistant Commissioner of Enforcement, Department of Banking and Insurance, PO Box 329, Trenton, NJ 08625-0329.

Authorized Signature: ____________________________________________

Date: _____/_____/_____ Phone Number: ( ____ ) ______________

Print Name and Title: ______________________________________________

Office Address: ___________________________________________________

E-mail Address: ___________________________________________________

2/2010