"General Agent Agreement Form" - Connecticut

General Agent Agreement Form is a legal document that was released by the Connecticut Insurance Department - a government authority operating within Connecticut.

Form Details:

  • Released on December 30, 2015;
  • 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 "General Agent Agreement Form" - Connecticut

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IMPORTANT NOTICE
To:
All Insurance Companies Authorized to Conduct Business in Connecticut
From:
Thomas B. Leonardi, Insurance Commissioner
Re:
Notification of Managing General Agent Agreement pursuant to CGS 38a-90
CGS 38a-90d. Duties of the insurer…(f) Within thirty days of entering into or termination of a contract with
a managing general agent, the insurer shall provide written notification of such appointment or termination
to the commissioner. Notices of appointment of a managing general agent shall include a statement of duties
which the applicant is expected to perform on behalf of the insurer, the lines of insurance for which the
applicant is authorized to act and any other information the commissioner may require.
Effective immediately, in lieu of providing Managing General Agent Agreements to the Insurance Department’s
Licensing Division, please provide all information requested below, for each Managing General Agent Agreement
(Contract) in effect in Connecticut, currently (whether Agreement previously submitted or not); and, on an ongoing
basis, submit this information each time you appoint or terminate a Managing General Agent or terminate a
Managing General Agent Agreement (Contract). The Contract must be available to Insurance Department Field
Examiners, when auditing your Company’s records.
The Company certifies that it has been provided with evidence of current licensure of such Producer, and has
submitted an appointment for such Producer to act on its behalf in Connecticut.
COMPANY INFORMATION
Company Name & NAIC #:
________________________________________________________________
PRODUCER INFORMATION
Connecticut Insurance Producer License Number:_____________________________________________________
Name of Producer:______________________________________________________________________________
FEIN/SSN:____________________________________________________________________________________
Lines of Authority:______________________________________________________________________________
MGA Agreement Commencement Date:_____________
MGA Agreement Termination Date:_____________
“Statement of Duties” pursuant to CGS 38a-90d:___________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
Completed by (Name & Title):______________________________________________Date:________________
Phone Number:________________________ Email Address:_________________________________________
You are required to complete and submit this form, within 30 days of MGA Agreement, or cancellation of such
Agreement, electronically to
cid.licensing@ct.gov
or by US Mail to:
STATE OF CONNECTICUT
INSURANCE DEPT – LICENSING DIVISION
PO BOX 816
HARTFORD, CT 06142-0816
Revised: December 30, 2015
IMPORTANT NOTICE
To:
All Insurance Companies Authorized to Conduct Business in Connecticut
From:
Thomas B. Leonardi, Insurance Commissioner
Re:
Notification of Managing General Agent Agreement pursuant to CGS 38a-90
CGS 38a-90d. Duties of the insurer…(f) Within thirty days of entering into or termination of a contract with
a managing general agent, the insurer shall provide written notification of such appointment or termination
to the commissioner. Notices of appointment of a managing general agent shall include a statement of duties
which the applicant is expected to perform on behalf of the insurer, the lines of insurance for which the
applicant is authorized to act and any other information the commissioner may require.
Effective immediately, in lieu of providing Managing General Agent Agreements to the Insurance Department’s
Licensing Division, please provide all information requested below, for each Managing General Agent Agreement
(Contract) in effect in Connecticut, currently (whether Agreement previously submitted or not); and, on an ongoing
basis, submit this information each time you appoint or terminate a Managing General Agent or terminate a
Managing General Agent Agreement (Contract). The Contract must be available to Insurance Department Field
Examiners, when auditing your Company’s records.
The Company certifies that it has been provided with evidence of current licensure of such Producer, and has
submitted an appointment for such Producer to act on its behalf in Connecticut.
COMPANY INFORMATION
Company Name & NAIC #:
________________________________________________________________
PRODUCER INFORMATION
Connecticut Insurance Producer License Number:_____________________________________________________
Name of Producer:______________________________________________________________________________
FEIN/SSN:____________________________________________________________________________________
Lines of Authority:______________________________________________________________________________
MGA Agreement Commencement Date:_____________
MGA Agreement Termination Date:_____________
“Statement of Duties” pursuant to CGS 38a-90d:___________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
Completed by (Name & Title):______________________________________________Date:________________
Phone Number:________________________ Email Address:_________________________________________
You are required to complete and submit this form, within 30 days of MGA Agreement, or cancellation of such
Agreement, electronically to
cid.licensing@ct.gov
or by US Mail to:
STATE OF CONNECTICUT
INSURANCE DEPT – LICENSING DIVISION
PO BOX 816
HARTFORD, CT 06142-0816
Revised: December 30, 2015