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Insurance Company Registration Form

Please fill out this form only if your company is licensed to provide automobile liability insurance in the State of Connecticut.


General Information
Company Name: NAIC Number:
Street Address: City:
State: Zip Code:
                     Does your company currently write automobile insurance in CT?
            Does your company issue ONLY commercial automobile policies in CT?
                                Does your company cover less than 500 vehicles in CT? 
Main/Functional Contact Details
First Name: Last Name:
Middle Initial: Phone Number:
Fax Number: Email Address:
Do you want to add a technical contact?
Do you want to add a compliance contact?
Web Login Information
User Name:
(Same as your Naic No)
Password:
Secret Question: Secret Question Answer:
 

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