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How to use or fill out fr19 2004 form with DocHub
- Click ‘Get Form’ to open the fr19 2004 form in our platform's editor.
- Begin by filling out the top section, listing each 'Insurer' company you are authorized to issue Maryland Insurance Certifications for. Ensure you include the date of request.
- Select the appropriate action from the options provided: New Request, Account Change, Account Deletion, Add Insurer Association, or Remove Insurer Association.
- Enter your User ID and Producer License Number issued by MD Ins Admin. Fill in your contact details including phone number and email address.
- List the insurers you are authorized to issue certifications for, including their NAIC codes. Use additional sheets if necessary.
- Complete the acknowledgment section regarding remote access responsibilities and sign with the date.
- Ensure that an Insurance Company or Agency Officer authorizes your request by signing in the designated area before submission.
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