# Countersignature Request And Record Form

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

## Policy Details
- **Policy No.:** 375175-02
- **Eff. Date:** 5/2/86
- **Exp. Date:** 5/21/87
- **Agency No.:** 50575810
- **Risk Acct. No.:** 9147651900
- **Named Insured:** John
- **Such premium is:** ☑️ (is subject to audit)
- **Kind of Insurance:** General Liability
- **Gross Commission:** 15%
- **Insured's State of Residence:** New York

## 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") |
|-----------|-------------|-------------------|---------------------|--------------------------------------------------------------------|
| Alaska    |             |                   |                     |                                                                    |
| Nevada    |             |                   |                     |                                                                    |
| Florida   |             |                   |                     |                                                                    |
| Ohio      |             |                   |                     |                                                                    |
| Kansas    |             |                   |                     |                                                                    |
| Puerto Rico|             |                   |                     |                                                                    |
| Louisiana |             |                   |                     |                                                                    |
| Utah      |             |                   |                     |                                                                    |
| Mississippi |             |                   |                     |                                                                    |
| Virginia  |             |                   |                     |                                                                    |

## 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: _______
## Date Completed: 6/1/86

## Form 5262 1J
- Processing Center: White
- Branch: Yellow
- Agent: Pink
- PC Premium Audit: Gold/Red
- Inv.: UGU-5262-1J