# Countersignature Request And Record Form

## Zurich Insurance Company
- **Office From (Branch Office):** Manhattan SIR
- **For - Producing Agency (Name & State):** Johnson & Higgins

## Policy Details
- **Policy No.:** 091478650
- **Eff. Date:** 5/21/84
- **Exp. Date:** 5/21/85
- **Agency No.:** 36617
- **Risk Acct. No.:** 91478650

## Named Insured
- **JBN**

## Kind of Insurance
- **General Liability**

## Gross Commission
- **1%**
- **Insured's State of Residence:** NY

## Issue countersignature endorsements for states where premium changes or notations are shown below:

| State (1) | Premium (2) | C/S Commission (3) | C/S Agent Number (4) | Number (5) | Expiration Date (6) | Name of person to whom issued (7) |
|-----------|-------------|--------------------|----------------------|------------|---------------------|----------------------------------|
| MD        | T.B.D       | Not assigned       | 174                  | 11/1/78    |                     |
| MA        | T.B.D       | 5% from max 50%    | 2419                 | 8/16/80    |                     |
| MI        | T.B.D       | Not assigned       | 34-239-91            | Team       |
| NJ        | T.B.D       | 5% from max 50%    | 2,6118               | 10/31/81   |                     |
| NY        | T.B.D       | Not assigned       |                      |           |
| NC        | T.B.D       | Do Not Code         | 100-129              | 2/21/79    |                     |
| OH        | T.B.D       | Not assigned       | 240-2291             | 6/3/74     |                     |
| RI        | T.B.D       | 2% from Term       | 62-581               | 8/14/79    |                     |
| TX        | T.B.D       | 5% from max 50%    | 36-754               | GA-185     | 11/14/80            |
| VT        | T.B.D       | Not assigned       | 47                   | 2/21/80    |                     |
| WI        | T.B.D       | Not assigned       | 6189                 | 11/1/79    |                     |

## Important - Please Note:
1. If policy is subject to audit, premium must be shown as "T.B.D." (i.e., "to be determined"). Countersignature fees on policies which are subject to audit adjustment will be computed and charged at the time of final premium determination.
2. The following states have special requirements. Consult the Countersignature state matrix.
- Alaska
- Nevada
- Florida
- Ohio
- Kansas
- Puerto Rico
- Louisiana
- Utah
- Mississippi
- Virginia

## C/S Clerk's Initials: FJ
## Date Completed: 4-85

## Form 5262 1-J
- **Processing Center: White**
- **Branch: Yellow**
- **Agent: Pink**
- **PC Premium Audit: Goldenrod**
- **Inv.: UGU5262-1-J**

## MM 009768