"Rental Car Agency Company Appointment Application Form" - Connecticut

Rental Car Agency Company Appointment Application Form is a legal document that was released by the Connecticut Insurance Department - a government authority operating within Connecticut.

Form Details:

  • Released on October 12, 2016;
  • The latest edition currently provided by the Connecticut Insurance Department;
  • Ready to use and print;
  • Easy to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a printable version of the form by clicking the link below or browse more documents and templates provided by the Connecticut Insurance Department.

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Download "Rental Car Agency Company Appointment Application Form" - Connecticut

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STATE OF CONNECTICUT
INSURANCE DEPARTMENT
Rental Car Agency Company Appointment Application
PART A: To be completed by the Rental Car Agency Permittee Application
Complete Part A and then forward this form to the Insurance Company(ies) which your company will
represent, for their completion.
Emailing or faxing this form is permitted.
Rental Car Agency Name:
___________________________________________________________________
Mailing Address (Address, City, State and Zip Code):
_____________________________________________________________________________________
Physical Address (This address cannot be a PO Box):
_____________________________________________________________________________________
Contact Person Information:
Name and Title: _________________________________________________________________
Email: ________________________________________________________________________
Phone Number: ___(______)_______________________________________________________
(Email address for Rental Car Agency is required)
Part B: To be completed by the Insurance Company
Complete and sign this application for the Rental Car Agency, which is requesting a permit from the
State of Connecticut, Insurance Department. Upon completion, return the form to the Rental Car
Agency, who will send with the completed Rental Car Agency Permit Application and fee.
Insurance Company Name: ______________________________________________________________
Connecticut Company Number: ___________________
NAIC Number: ____________________
Mailing Address (Address, City, State and Zip Code):
_____________________________________________________________________________________
Contact Person Information:
Name and Title: _________________________________________________________________
Email: ________________________________________________________________________
Phone Number: ___(______)_______________________________________________________
(Email address for Insurance Company is required)
www.ct.gov/cid
P.O. Box 816 Hartford, CT 06142-0816
An Equal Opportunity Employer
Rental Car Agency Company Appointment Application (Revised: 10/12/2016)
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STATE OF CONNECTICUT
INSURANCE DEPARTMENT
Rental Car Agency Company Appointment Application
PART A: To be completed by the Rental Car Agency Permittee Application
Complete Part A and then forward this form to the Insurance Company(ies) which your company will
represent, for their completion.
Emailing or faxing this form is permitted.
Rental Car Agency Name:
___________________________________________________________________
Mailing Address (Address, City, State and Zip Code):
_____________________________________________________________________________________
Physical Address (This address cannot be a PO Box):
_____________________________________________________________________________________
Contact Person Information:
Name and Title: _________________________________________________________________
Email: ________________________________________________________________________
Phone Number: ___(______)_______________________________________________________
(Email address for Rental Car Agency is required)
Part B: To be completed by the Insurance Company
Complete and sign this application for the Rental Car Agency, which is requesting a permit from the
State of Connecticut, Insurance Department. Upon completion, return the form to the Rental Car
Agency, who will send with the completed Rental Car Agency Permit Application and fee.
Insurance Company Name: ______________________________________________________________
Connecticut Company Number: ___________________
NAIC Number: ____________________
Mailing Address (Address, City, State and Zip Code):
_____________________________________________________________________________________
Contact Person Information:
Name and Title: _________________________________________________________________
Email: ________________________________________________________________________
Phone Number: ___(______)_______________________________________________________
(Email address for Insurance Company is required)
www.ct.gov/cid
P.O. Box 816 Hartford, CT 06142-0816
An Equal Opportunity Employer
Rental Car Agency Company Appointment Application (Revised: 10/12/2016)
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(Rental Car Agency Name and Address):
____________________________________________________________________________________
Is here by appointed to transact business, to solicit, to negotiate or effect contracts of insurance on
behalf of
____________________________________________________________________________________.
(Insurance Company Name)
Name above, only in the limited capacities which are relevant to the business of vehicle rentals, as set
forth in C.G.S. 38a-799(b)(1-4).
The following insurance coverage will be officered on Connecticut approved forms by the
____________________________________________________________________________________.
Pertinent to this appointment (Check all that apply):
______ Personal accident insurance covering risk of travel, including accident and health insurance,
accident death or dismemberment and reimbursement for medical expenses.
______ Liability insurance, including uninsured and underinsured motorist coverage, for liability arising
from the operation of the rental vehicle.
______ Personal effects insurance that provides coverage for loss of, or damage to personal effects of
the renter or other vehicle occupants.
______ Roadside assistance and emergency sickness protection program.
The undersigned, being an insurer authorized to do insurance business in the State of Connecticut;
hereby states that it intends to appoint the above named applicant, if duly authorized, to act as its agent
for the line(s) of insurance set forth herein. The appointment will be effective when the permit
application is approved by the State of Connecticut, Insurance Department.
Additionally, the undersigned understands that the appointment made herein is considered by the
Connecticut Insurance Department to be perpetual. It will remain valid unless and until terminated by
the Insurance Company which is represented by the undersigned. Any such terminations must be sent in
writing to this Department and must include termination date and reason.
_____________________________________________________________________________________
Authorized Signature and Date
_____________________________________________________________________________________
Print or Type Name and Title of Signatory
_____________________________________________________________________________________
Print or Type Contact Person for Insurance Company (Name, Title and Email)
Rental Car Agency Company Appointment Application (Revised: 10/12/2016)
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