Form FIS0242 "Managing General Agent or Agency Appointment / Cancellation" - Michigan

What Is Form FIS0242?

This is a legal form that was released by the Michigan Department of Insurance and Financial Services - a government authority operating within Michigan. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on May 1, 2015;
  • The latest edition provided by the Michigan Department of Insurance and Financial Services;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a fillable version of Form FIS0242 by clicking the link below or browse more documents and templates provided by the Michigan Department of Insurance and Financial Services.

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Download Form FIS0242 "Managing General Agent or Agency Appointment / Cancellation" - Michigan

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This form should be completed ONLY by the
FIS 0242 (5/15) Department of Insurance and Financial Services
Page 1 of 1
Insurance Company appointing / cancelling the
Managing General AGENT or AGENCY Appointment / Cancellation
.
Managing General Agent or Agency
Name of Insurance Company
Company NAIC number
Complete a separate form for each Managing General AGENT or Managing General AGENCY. If submitting an appointment for a Managing General
AGENCY, an appointment must also be submitted for a Managing General AGENT within that agency, using a separate FIS 0242 form.
Name of AGENT
Name of AGENCY
OR
AGENT Mailing Address
AGENCY Mailing Address
City
State
ZIP Code
City
State
ZIP Code
Agent System ID/License number
Agency System ID/License number
Agent Social Security number (last 4 digits only)
Agency Tax ID number (FEIN)
Action Requested:
Effective Date of this action:
APPOINT this Agent or Agency for these lines:
CANCEL this Agent or Agency for these lines:
Life
Property
Life
Property
Accident and Health
Casualty
Accident and Health
Casualty
If appointing a Managing General AGENT or AGENCY, briefly state the duties they are expected to perform on behalf of the Insurer:
Certification
This appointment or cancellation of a Managing General Agent or Agency is done pursuant to Section 500.1411(e) of the Michigan Insurance Code. I am authorized by this Insurer to
appoint or cancel this agent or agency. I am familiar with the requirements of Chapter 14 of the Michigan Insurance Code, and assure that the Company and its Managing General
Agents and Agency will comply with its provisions.
Name and Title of Appointing Authority (typed or printed)
Submit by Mail or Fax to:
DIFS Insurance Licensing
Address Line 1
P. O. Box 30220
Lansing, MI 48909-7720
Address Line 2
Fax Number: (517) 284-8836
City
State
ZIP Code
Telephone number
Email Address
Signature of Appointing Authority
Date signed
Authority: This information is required pursuant to Section 500.1411(e) of the Michigan Insurance Code. Failure to file this information may result in further compliance action including
and up to a fine and/or limitation of your Certificate of Authority in Michigan.
This form should be completed ONLY by the
FIS 0242 (5/15) Department of Insurance and Financial Services
Page 1 of 1
Insurance Company appointing / cancelling the
Managing General AGENT or AGENCY Appointment / Cancellation
.
Managing General Agent or Agency
Name of Insurance Company
Company NAIC number
Complete a separate form for each Managing General AGENT or Managing General AGENCY. If submitting an appointment for a Managing General
AGENCY, an appointment must also be submitted for a Managing General AGENT within that agency, using a separate FIS 0242 form.
Name of AGENT
Name of AGENCY
OR
AGENT Mailing Address
AGENCY Mailing Address
City
State
ZIP Code
City
State
ZIP Code
Agent System ID/License number
Agency System ID/License number
Agent Social Security number (last 4 digits only)
Agency Tax ID number (FEIN)
Action Requested:
Effective Date of this action:
APPOINT this Agent or Agency for these lines:
CANCEL this Agent or Agency for these lines:
Life
Property
Life
Property
Accident and Health
Casualty
Accident and Health
Casualty
If appointing a Managing General AGENT or AGENCY, briefly state the duties they are expected to perform on behalf of the Insurer:
Certification
This appointment or cancellation of a Managing General Agent or Agency is done pursuant to Section 500.1411(e) of the Michigan Insurance Code. I am authorized by this Insurer to
appoint or cancel this agent or agency. I am familiar with the requirements of Chapter 14 of the Michigan Insurance Code, and assure that the Company and its Managing General
Agents and Agency will comply with its provisions.
Name and Title of Appointing Authority (typed or printed)
Submit by Mail or Fax to:
DIFS Insurance Licensing
Address Line 1
P. O. Box 30220
Lansing, MI 48909-7720
Address Line 2
Fax Number: (517) 284-8836
City
State
ZIP Code
Telephone number
Email Address
Signature of Appointing Authority
Date signed
Authority: This information is required pursuant to Section 500.1411(e) of the Michigan Insurance Code. Failure to file this information may result in further compliance action including
and up to a fine and/or limitation of your Certificate of Authority in Michigan.