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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.