RIIVS


Insurance Company Registration Form Please fill out this form only if your company is licensed to provide automobile liability insurance in the State of Rhode Island.


General Information
Company Name:	*	NAIC Number:	* *
Street Address:	*	City:	*
State:		Zip Code:	* *
* Does your company currently write automobile insurance in RI? YesNo
* Does your company issue ONLY commercial automobile policies in RI? YesNo
* Does your company cover less than 50 private passenger vehicles in RI? YesNo

Main/Functional Contact Details
First Name:	*	Last Name:	*
Middle Initial:		Phone Number:	* *
Fax Number:		Email Address:	**
Do you want to add a technical contact?
Do you want to add a compliance contact?

Web Login Information
User Name:	(Same as your Naic No)	Password:	* *
Secret Question:	*	Secret Question Answer:	* *