NCJUA-NCIUA

North Carolina Joint Underwriting Association (FAIR Plan)
North Carolina Insurance Underwriting Association (Coastal Property Insurance Pool)

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To be completed by the individual responsible receiving commission statements

Please complete and submit all of the questions below.

Name (Last, First)Required


Job TitleRequired


Producer CodeRequired


Please provide the email address to send all secure correspondence regarding commission.Required


What is your phone number? (xxx)xxx-xxxxRequired


Security Questions:

What is your Agency’s Federal Tax ID Number?Required


What was your 2011 annual commission volume for NCJUA? If you do not write any NCJUA policies, please type N/A. If amount is not known, please type unknown.Required


What was your 2011 annual commission volume for NCIUA? If you do not write any NCIUA policies, please type N/A. If amount is not known, please type unknown.Required


If applicable, what is the year, month and the amount of your last NCIUA commission statement? Please use the format: 2012 - June $1000. If not applicable, please type N/A. Required


If applicable, what are the last 4 digits on the bank account number in which your current NCIUA commissions are electronically deposited? If not applicable, please type N/A.
Required


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