MAIPF Agency Information Form

Submit this form whenever changes (i.e. new employee, retiree, change of TIN, etc.) occur so we can update your records. Passwords cannot be created until we receive this form and we have verified licensing status (usually within 1 working day after receipt of this form). See http://www.maipf.org/LoginInfo.aspx for new user instructions. * Required Field

Agency/Producer Name:

Federal ID Number:

Address Type:

Commercial

Residential

Street Address:

* (Check if this is a new address)

PO Box:

Suite:

City:

* State: * Zip: *

Office Phone:

* (include area code)

Office Fax:

* (include area code)

Office Email:

Submitted By:

Please list ALL individuals in your office who hold a resident or non-resident agent's license (not a solicitor's license) and are appointed by your voluntary company(s) to write in the State of Michigan through your agency.
This information is for internal use only and will not be published or distributed.