The Illinois FAIR Plan Association  

Contact Us: info@illinoisfairplan.com 312.861.0385   

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This form is for agents licensed in the State of Illinois who wish to register as a producer for the Illinois FAIR Plan Association. Please contact us with any comments or questions.

Name under which you are licensed or registered to do business:

 

Name under which you will be doing business with us (if different from above):

 

Contact Name:
Mailing Address:
City:
State:
Zip Code:
Telephone:
Fax:
E-mail:
  required

 

Illinois Resident Producer's License Number:

 

Class(es) of License:

 

Tax ID number or Social Security Account Number under which income is to be reported:

 

Specify Company Affiliation:

 

Independent Agent
Name of Agency:
Single Company Representation
Name of Company:

 

I certify that I am licensed as a resident producer to do business in Illinois under the name and/or license number listed on this card.

 


 

 

 

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