# Countersignature Request And Record Form

## Zurich Insurance Company

**To Countersigning Clerk:** [Name and Title]
**Office From (Branch Office):** [Branch Office Name]

**For - Producing Agency (Name & State):** [Agency Name & State]

**Policy No.:** [Policy Number]
**Eff. Date:** [Effective Date]
**Exp. Date:** [Expiration Date]
**Agency No.:** [Agency Number]
**Risk Acct. No.:** [Risk Account Number]

**Named Insured:** [Named Insured]
**Such premium:** [Is/Is not subject to audit]

**Kind of Insurance:** [Type of Insurance]
**Gross Commission:** [Commission Amount]
**%:** [Percentage]
**Insured's State of Residence:** [State]

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

| State (1) | Premium (2) | CIS Commission (3) | CIS Agent Number (4) | Producer's Non-Resident License Data (no entry means "no license") |
|-----------|-------------|--------------------|----------------------|------------------------------------------------------------------|
| [State]   | [Premium]   | [CIS Commission]   | [Agent Number]       | [Number]                                                         |
| [State]   | [Premium]   | [CIS Commission]   | [Agent Number]       | [Number]                                                         |
| [State]   | [Premium]   | [CIS Commission]   | [Agent Number]       | [Number]                                                         |
| [State]   | [Premium]   | [CIS Commission]   | [Agent Number]       | [Number]                                                         |
| [State]   | [Premium]   | [CIS Commission]   | [Agent Number]       | [Number]                                                         |
| [State]   | [Premium]   | [CIS Commission]   | [Agent Number]       | [Number]                                                         |
| [State]   | [Premium]   | [CIS Commission]   | [Agent Number]       | [Number]                                                         |
| [State]   | [Premium]   | [CIS Commission]   | [Agent Number]       | [Number]                                                         |
| [State]   | [Premium]   | [CIS Commission]   | [Agent Number]       | [Number]                                                         |
| [State]   | [Premium]   | [CIS Commission]   | [Agent Number]       | [Number]                                                         |

**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:** [Date]

**Form 5262 1J**
**Processing Center-White Branch-Yellow Agent-Pink PC Premium Audit-Goldenrod**
**Inv. UGUS262-1J**
**MM 009770**