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CARRIER CONTACT INFORMATION
This form is to be completed by an authorized representative of the company. This form is to be used to establish a contact/distribution list for the WAIP or to amend previously furnished information.
Please provide the following information:
Is this to amend previous information?
* = Required Field
*
Carrier Name:
*
Contact Name:
*
Department:
*
Address:
*
City:
State:
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
District of Columbia
Delaware
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
*
Zip:
*
E-mail Address:
*
Business Phone Number:
(
)
-
ext
*
Business Fax Number:
(
)
-
Mobile Phone Number:
(
)
-
Web Page Address:
Additional Instructions/Comments:
If this individual represents additional carriers within your group, please list the carriers below:
Please complete and submit this form for each individual to be added to the WAIP distribution list.
It is your responsibility to update the Plan office of all future changes.
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