| Applicant for Best's Directory of Third Party Administrators |
The below information will be used for both General and Full listings.
Bold fields are required. |
| TO BE COMPLETED BY ALL APPLICANTS |
| Firm Name: | |
| Street Address 1: | |
| Street Address 2: | |
| City: | |
| State/Province: | |
| Country: | |
| Zip/Postal Code: | |
| Firm Telephone: | |
| Firm Fax: | |
| Firm Website: | |
| Firm Email: | |
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| Contact Person: | Title: |
| Contact Telephone: | |
| Contact Email: | |
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| TO BE COMPLETED BY FULL LISTING APPLICANTS ONLY |
Client Verification - please list at least one client who A.M. Best can contact to qualify you as a recommended listee.- A minimum of one Client is required in order to process.
- Only include one contact for each Client.
- Must provide either a phone, email or fax number for each client contact.
- Include name and complete address of individual branch office or department for Client where verification letter will be sent.
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| Client 1: |
| Client Firm Name: Contact Person: Title: |
| Street Address /P.O. Box: City: Country: State/Province: |
| Zip/Postal Code: Firm Telephone: Fax: Email: |
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| Client 2: |
| Client Firm Name: Contact Person: Title: |
| Street Address /P.O. Box: City: Country: State/Province: |
| Zip/Postal Code: Firm Telephone: Fax: Email: |
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| Client 3: |
| Client Firm Name: Contact Person: Title: |
| Street Address /P.O. Box: City: Country: State/Province: |
| Zip/Postal Code: Firm Telephone: Fax: Email: |
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| Client 4: |
| Client Firm Name: Contact Person: Title: |
| Street Address /P.O. Box: City: Country: State/Province: |
| Zip/Postal Code: Firm Telephone: Fax: Email: |
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| Client 5: |
| Client Firm Name: Contact Person: Title: |
| Street Address /P.O. Box: City: Country: State/Province: |
| Zip/Postal Code: Firm Telephone: Fax: Email: |
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| Client 6: |
| Client Firm Name: Contact Person: Title: |
| Street Address /P.O. Box: City: Country: State/Province: |
| Zip/Postal Code: Firm Telephone: Fax: Email: |
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| Client 7: |
| Client Firm Name: Contact Person: Title: |
| Street Address /P.O. Box: City: Country: State/Province: |
| Zip/Postal Code: Firm Telephone: Fax: Email: |
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| Client 8: |
| Client Firm Name: Contact Person: Title: |
| Street Address /P.O. Box: City: Country: State/Province: |
| Zip/Postal Code: Firm Telephone: Fax: Email: |
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| Submitter Name: | |
| Submitter Email: | |
| Submitter Phone: | |
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