Purchase or Complimentary Distribution
Directory Purchase
Name:
Title:
Co. Name:
Address:
City:
State:
Zip:
Phone:
Fax:
Email:
Business Description:
Enter number of directories to be ordered:
	Insurance Bar ($99.00 each) Claim Service Guide ($99.00 each) Independent Agent Handbooks ($65.00 each)
Payment:	Enclosed (Print the form & mail with check) Credit Card (Submit the form & we will contact you)

Complimentary Distribution Complimentary distribution is limited to claim managers, supervisors, self insureds, etc. for use in claim assignments and legal referrals.
Action Needed:	New Company Existing Company, Change Info Delete Company
Co. Name:
Address (old/existing):
City (old/existing):
State (old/existing):
Zip (old/existing):
Address (new, if app):
City (new, if app):
State (new, if app):
Zip (new, if app):

Name, Title (Complete for each action)		Number of Books			Action
		IB	CSG	Agent Handbooks	New Name & No. of Books	Delete	Same name & No. of Books
1.
2.
3.

Other Requests: