STATE OF NEW MEXICO – OFFICE OF SUPERINTENDENT OF INSURANCE ...
STATE OF NEW MEXICO ? OFFICE OF SUPERINTENDENT OF INSURANCE (OSI) PRODUCER LICENSING BUREAU
Business Entity Affiliation Form
Business Entity Federal Id Number ___________________________________License Number __________ Business Entity Name______________________________________________________________________ Address _____________________________________City _____________________State Zip____________ Contact Person ___________________________________________ Telephone No. ___________________ Email Address___________________________________
Notice is hereby given that effective from the date shown on this notice, the designated business entity hereby affiliates the licensee(s) named herein to act as its affiliate.
Affiliation fee is $20.00 per affiliate. We do not affiliate agencies. Please list only individual agents.
Payment must be made by Check, Money Order, ACH Credit or Wire.
NAME AS SHOWN ON LICENSE Example: John Smith
NPN AND LICENSE TYPE 12345 ? Independent Adjuster
Please have only 6 affiliations per form, we will not accept "attached spreadsheets"
Total affiliations ____________
$20.00 per affiliate = $___________
Check _____ Money Order _____ ACH Credit __________ or Wire __________
Signature must be that of an officer of the business entity or a person authorized by the business entity to sign on behalf of the business entity.
Printed Name ______________________________________ Official Title___________________________ Signature ________________________________________ Date ________________________________
For electronic payments: Once you have made payment via ACH Credit or Wire, please email this form to agents.licensing@state.nm.us
All filing fees are non-refundable or non-transferable, whether or not the application is processed. Per NMSA 59A-6-1 all fees are earned when paid and are not refundable.
Affiliation Form 202B
Revised October 2020
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