"Self-service Storage Space Insurance Locations" - Kentucky

Self-service Storage Space Insurance Locations is a legal document that was released by the Kentucky Department of Insurance - a government authority operating within Kentucky.

Form Details:

  • Released on July 1, 2014;
  • The latest edition currently provided by the Kentucky Department of Insurance;
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Form – Self-Service Storage Space Insurance Locations
Rev. 7/2014
KENTUCKY DEPARTMENT OF INSURANCE
AGENT LICENSING DIVISION
PO BOX 517
FRANKFORT, KY 40602
(502) 564-6004
DOI.AGENTLICENSINGMAIL@KY.GOV
HTTP://INSURANCE.KY.GOV
As required by KRS 304.9-496, a self-service storage space insurance producer shall establish and maintain a register of each facility that offers self-service storage space
insurance, on the insurance producer’s behalf. This register shall be maintained and updated annually by the limited lines self-service storage space insurance producer, and is
open to inspection and audit by the insurance commissioner upon request. This form may be photo-copied as needed.
Name of Self-Service Storage Space Insurance Producer:___________________________________________________________________________________
KY DOI#:_________________ or NPN:_____________________
Name of Designated Licensed Insurance Producer:________________________________________________________________________________________
KY DOI#:_________________ or NPN:_____________________
This register is current as of ___________________
(Date)
Name of Facility
FEIN
Location Street Address
Location City, State, Zip Code
Telephone /email address
Name of Unlicensed Officer/Employee/Facility Operator
Personal Street Address
Personal City, State, Zip Code
Personal Telephone/email address
Certification --- As an authorized representative of the Self-Service Storage Space Insurance Producer, I certify that the listing above represents all business locations, including the names and contact
information of each unlicensed officer, employee, or facility operator who offers and disseminates insurance information. Each individual has received appropriate training and instruction on the
types of insurance offered, ethical sales practices, and required disclosures to prospective customers. Additionally, it is certified that the self-service storage space insurance producer complies with
18 U.S.C. sec. 1033.
Signature of Authorized Representative
Title
Date
Printed Name of Authorized Representative
Form – Self-Service Storage Space Insurance Locations
Rev. 7/2014
KENTUCKY DEPARTMENT OF INSURANCE
AGENT LICENSING DIVISION
PO BOX 517
FRANKFORT, KY 40602
(502) 564-6004
DOI.AGENTLICENSINGMAIL@KY.GOV
HTTP://INSURANCE.KY.GOV
As required by KRS 304.9-496, a self-service storage space insurance producer shall establish and maintain a register of each facility that offers self-service storage space
insurance, on the insurance producer’s behalf. This register shall be maintained and updated annually by the limited lines self-service storage space insurance producer, and is
open to inspection and audit by the insurance commissioner upon request. This form may be photo-copied as needed.
Name of Self-Service Storage Space Insurance Producer:___________________________________________________________________________________
KY DOI#:_________________ or NPN:_____________________
Name of Designated Licensed Insurance Producer:________________________________________________________________________________________
KY DOI#:_________________ or NPN:_____________________
This register is current as of ___________________
(Date)
Name of Facility
FEIN
Location Street Address
Location City, State, Zip Code
Telephone /email address
Name of Unlicensed Officer/Employee/Facility Operator
Personal Street Address
Personal City, State, Zip Code
Personal Telephone/email address
Certification --- As an authorized representative of the Self-Service Storage Space Insurance Producer, I certify that the listing above represents all business locations, including the names and contact
information of each unlicensed officer, employee, or facility operator who offers and disseminates insurance information. Each individual has received appropriate training and instruction on the
types of insurance offered, ethical sales practices, and required disclosures to prospective customers. Additionally, it is certified that the self-service storage space insurance producer complies with
18 U.S.C. sec. 1033.
Signature of Authorized Representative
Title
Date
Printed Name of Authorized Representative