# Countersignature Request And Record Form

## Zurich Insurance Company
- **Address:** The Zurich Building, Schaumburg, IL 60196

## Form Details
- **Form Number:** 5262 1J
- **Processing Center:** White
- **Branch:** Yellow
- **Agent:** Pink
- **PC Premium Audit:** Goldenrod
- **Inv.:** U-GU5262-1-J
- **MM:** 009773

## To Countersigning Clerk
- **Office From (Branch Office):** Max Rathau SIR

## For Producing Agency (Name & State)
- **Agency Name:** T. L. S. C., & Higgins
- **State:** NJ

## Policy Information
- **Policy No.:** 12345678-02
- **Eff. Date:** 5/31/56
- **Exp. Date:** 6/31/87
- **Agency No.:** E0517810
- **Risk Acct. No.:** 914765198

## Named Insured
- **TPM**

## Premium Information
- **Such premium is not subject to audit.**

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

## Gross Commission
- **4.5%**

## Insured's State of Residence
- **New York**

## Issue Countersignature Endorsements for States Where Premium Changes or Notations Are Shown Below:

| State | Premium | CS Commission | CS Agent Number | Number | Expiration Date | Name of person to whom issued |
|-------|---------|---------------|-----------------|--------|-----------------|--------------------------------|
| NY    | T.B.D. | Non Resident  | 666-17          |        |                 |                                |
| NJ    |         | Not required  |                 |        |                 |                                |
| PA    |         | Non Resident  |                 |        |                 |                                |
| MD    |         | Not required  |                 |        |                 |                                |
| VA    |         | Non Resident  |                 |        |                 |                                |
| NC    |         | Non Resident  |                 |        |                 |                                |
| OH    |         | Non Resident  |                 |        |                 |                                |
| IN    |         | Non Resident  |                 |        |                 |                                |
| MO    |         | Non Resident  |                 |        |                 |                                |
| HI    |         | Non Resident  |                 |        |                 |                                |
| VT    |         | Non Resident  |                 |        |                 |                                |

## 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

## CS Clerk's Initials: [Initials]
- **Date Completed:** 6/20/56

## Producer's Non-Resident License Data
- **No entry means "no license"**
- **Number:** 
- **Expiration Date:** 
- **Name of person to whom issued:**