MAIPF
Form for Bulletin No. 159
Lines of Insurance
Bulletin 159 | Form to Complete by Hand
Please Complete by December 30, 2005

To place business in the Michigan Automobile Insurance Placement Facility, agents must be licensed as a resident or non-resident agent by a company that writes auto casualty insurance in Michigan.

To update our records in this changing marketplace, we are requesting that you indicate which lines of insurance your company currently writes in Michigan.

Your Company Name:  
Date:  
Your Name:  
Your Title:  
Phone Number:  
E-mail Address:  

Private Passenger Auto (Liability & Physical Damage)  YesNo
Commercial Auto (Liability & Physical Damage)  YesNo
Currently writing in Michigan?  YesNo
Other -- Please indicate which line(s):
 
Submit one form for each company.
 
 
If you have any problems with this form,
please call 734.464.1100 x 222 or
send an e-mail message.


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