# 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, NY.

**Policy No.:** 6L327678-02
**Eff. Date:** 5-21-87
**Exp. Date:** 5-21-88
**Agency No.:** 50515816
**Risk Acct. No.:** 9147651900

**Named Insured:** TELT

**Such premium is ☑ is not subject to audit.**

**Kind of Insurance:** GENERAL LIABILITY

**Gross Commission:** 49%
**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') | Number (5) | Expiration Date (6) | Name of person to whom issued (7) |
|-----------|-------------|-------------------|---------------------|------------------------------------------------------------------|------------|--------------------|------------------------------------|
| AL        | TED         | 50% OF COMM       | 75-631              |                                                                 |            |                    |                                     |
| AZ        |             | 5% PREMIUM        | 75-631              |                                                                 |            |                    |                                     |
| IA        |             | RETALIATORY       |                     |                                                                 |            |                    |                                     |
| IN        |             | RETALIATORY       |                     |                                                                 |            |                    |                                     |
| KS        |             | NOT REQUIRED       |                     |                                                                 |            |                    |                                     |
| LA        |             | NOT REQUIRED       |                     |                                                                 |            |                    |                                     |
| FL        |             | 15% COMM          | 75-631              |                                                                 |            |                    |                                     |
| IL        |             | RETALIATORY       |                     |                                                                 |            |                    |                                     |
| IN        |             | 5% OF PREMIUM     | 64-036              |                                                                 |            |                    |                                     |
| KS        |             | NOT REQUIRED       |                     |                                                                 |            |                    |                                     |
| KY        |             | 1% OF PREMIUM     | 21-606              |                                                                 |            |                    |                                     |

## 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:** RV
**Date Completed:** 5-20-87

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

**MM 009775**