Massachusetts Authorization To Certify Motor Vehicle Insurance Coverage Form

Transcript

AUTHORIZATION TO CERTIFY MOTOR VEHICLE INSURANCE COVERAGE The , (Agency's Legal Name) being duly authorized under Chapter 175 of the General Laws of the Commonwealth of Massachusetts as an insurance producer licensed to sell, solicit and negotiate insurance, and further certified as an Assigned Risk Producer (ARP) for the Massachusetts Automobile Insurance Plan (MAIP) pursuant to the Commonwealth Automobile Reinsurers (CAR) Rules of Operation, hereby (please check the applicable box) grants revokes this limited durable power of attorney, authorizing the following individual(s): Name of Employee (Print) Name of Employee (Print) Employer Employer Office Location (Town) Office Location (Town) to certify, through the use of the MAIP stamp provided to the ARP by CAR, the existence of motor vehicle insurance coverage for risks assigned to an Assigned Risk Company by CAR. Such authority is extended only to those policies issued through the Massachusetts Automobile Insurance Plan and produced in the course of the individual's employment agreement with the insurance agency. This instrument shall be effective upon receipt by CAR. A grant of authority continues until revoked by the agent with notice to CAR. Name - Print full name of agent as licensed Email Title _________________________________________ Signature (Completed and signed forms may be faxed to the Residual Market Service Department at 617-880-7298). Print