# Countersignature Request And Record Form

## Zurich Insurance Company
- **To Countersigning Clerk:** [Name]
- **Office From (Branch Office):** Manhattan S/R
- **For - Producing Agency (Name & State):** Johnson & Higgins
- **Policy No.:** CG1278678
- **Eff. Date:** 5/31/84
- **Exp. Date:** 5/31/84
- **Agency No.:** 50-515-810
- **Risk Acct. No.:** 46617916765195
- **Named Insured:** IBM
- **Such premium:** TBD
- **Kind of Insurance:** General Liability
- **Gross Commission:** TBD
- **Insured's State of Residence:** NY
- **Issue countersignature endorsements for states where premium changes or notations are shown below:**

| State (1) | Premium (2) | CS Commission (3) | CS Agent Number (4) | Producer's Non-Resident License Data (no entry means "no license") |
|-----------|-------------|-------------------|---------------------|------------------------------------------------------------------|
| AL        | TBD         | 50% commission     | 28-355              | 324                  | 12/31/78             |
| AZ        | TBD         | 50% commission     | 79-399              | 38630               | 11/1/78             |
| CA        | TBD         | Not issued         | 877536              |                      | 6/20/80             |
| CO        | TBD         | 70% commission     | 108171              |                      | 11/1/79             |
| CT        | TBD         | Not issued         | 208500              |                      | 11/20/79            |
| DE        | TBD         | Not issued         | 302387              |                      | 11/20/79            |
| FL        | TBD         | 25% commission     | 84-130              | 772-2435            | 11/20/99            |
| IL        | TBD         | 50% commission     | 261390390           | 5/29/31             |
| IN        | TBD         | 50% commission     | 24030              | 70116               | 11/20/79            |
| KS        | TBD         | 50% commission     | 587425              |                      | 5/11/79             |
| KY        | TBD         | 50% commission     | 22-606              | 172-22-1279          | 8/11/79             |

## 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: [Initials]
Date Completed: 11/1/85

Form 5262 1J
Processing Center-White Branch-Yellow Agent-Pink PC Premium Audit-Goldenrod
Inv. UGU-5262-1J
MM 009769