North Carolina Department of Insurance, Wayne Goodwin Commissioner
 
Agent Services Division
COMPANY CONTACT INFORMATION
 
Company Contact Information
 
Please complete the form below, required fields are in RED.
 
COMPANY NAME: 
NAIC COMPANY NUMBER (IF APPLICABLE): 
ADJUSTING FIRM NUMBER (IF APPLICABLE): 
LICENSE PERMIT NUMBER (IF APPLICABLE): 
 
PRIMARY LICENSING CONTACT FIRST NAME: 
PRIMARY LICENSING CONTACT LAST NAME: 
PRIMARY LICENSING CONTACT TITLE: 
PRIMARY LICENSING CONTACT E-MAIL: 
 
*SECONDARY LICENSING CONTACT FIRST NAME: 
*SECONDARY LICENSING CONTACT LAST NAME: 
SECONDARY LICENSING CONTACT TITLE: 
*SECONDARY LICENSING CONTACT E-MAIL: 
 
MAILING ADDRESS: 
CITY:  STATE:  ZIP: 
 
  
 
*If you are providing and e-mail address for an employee, please provide a secondary contact and e-mail address. Contact the Agent Services Division at (919) 807-6800 if you have any questions.
 
If you operate under several company names, complete a form for each company.