DUE ANNUALLY on or before December 31st of the current year FIS 0524 (11/03) Office of Financial and Insurance Services Issuer-Agent Renewal Name of Issuer Your Issuer number Address (street address, NOT PO Box) Issuer MAILING ADDRESS (enter if different than address listed at left) City State Check if your address has changed since your last renewal Zip Code Tax ID number (FEIN) Check if your mailing address has changed since your last renewal Contact person name and title Contact person phone number Contact person email address Issuer-Agent listing List each agent of this issuer. You may use the space below, or attach a substitute list prepared on your office automation equipment. If you choose a substitute list, it must provide the same information in the same order as the format below. It must be in an easily readable typeface, 10 pt. or larger. 1 3 Name of agent Home address (must be street address--no PO Boxes) City Home address (must be street address--no PO Boxes) State Zip Code City Agent Social Security Number 2 Name of agent State Zip code Agent Social Security Number 4 Name of agent Home address (must be street address--no PO Boxes) City Name of agent Home address (must be street address--no PO Boxes) State Zip Code Agent Social Security Number City State Zip Code Agent Social Security Number Renewal Fee Calculation—Each Issuer-Agent is subject to a $65 per agent renewal fee. Complete table below. Quantity Mail completed form and any attachments with payment to: Amount Due Agent Renewal (quantity x $65.00) C3 Validation code: 9 Make check for full amount due payable in US dollars to: State of Michigan Office of Financial and Insurance Services Qualification Assessment/Licensing Section 611 W Ottawa St PO Box 30220 Lansing MI 48909-3127 Certification I swear under penalty of perjury that the information given in and attached to this application is true, complete and correct. Signature of officer, member or owner Date signed Signer's name and title (typed or printed) Authority: PA 265 of 1964 as amended. Failure to properly file will result in expiration of your registration. Visit OF IS on the Web at: www.michigan.gov/ofis Phone OF IS toll-free at: 1-877-999-6442 The Department of Consumer & Industry Services will not discriminate against any individual or group because of race, sex, religion, age, national origin, color, marital status, political beliefs or disability. If you need help with reading, writing, hearing, etc., under the Americans with Disabilities Act, you may make your needs known to this agency. American LegalNet, Inc. www.FormsWorkflow.com