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Personal Lines Rater Sign-up Form

1. Agency Name:
2. Agency Contact (First and Last Name):
3. Contact Email:
4. Contact Title:
5. Contact Phone Number:
6. Extension:
7. Do you have an existing Rating System?:
8. If Yes please specify which Rating System:
9. Rating States?:
10. Carriers you represent directly that you are interested in receiving real-time comparative rates from:
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