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Massachusetts Authorization to Certify Motor Vehicle Insurance Coverage Form


Massachusetts Authorization to Certify Motor Vehicle Insurance Coverage Form
Massachusetts Authorization to Certify Motor Vehicle Insurance Coverage Form
AUTHORIZATION TO CERTIFY MOTOR VEHICLE INSURANCE COVERAGE
The ,
(Agency's Legal Name)
being duly authorized under Chapter 175 of the General Laws of the Commonwealth of Massachusetts as an
insurance producer licensed to sell, solicit and negotiate insurance, and further certified as an Assigned Risk
Producer (ARP) for the Massachusetts Automobile Insurance Plan (MAIP) pursuant to the Commonwealth
Automobile Reinsurers (CAR) Rules of Operation, hereby
(please check the applicable box)
grants revokes
this limited durable power of attorney, authorizing the following individual(s):
Name of Employee (Print)
Name of Employee (Print)
Employer
Employer
Office Location (Town)
Office Location (Town)
to certify, through the use of the MAIP stamp provided to the ARP by CAR, the existence of motor vehicle
insurance coverage for risks assigned to an Assigned Risk Company by CAR. Such authority is extended
only to those policies issued through the Massachusetts Automobile Insurance Plan and produced in the
course of the individual's employment agreement with the insurance agency.
This instrument shall be effective upon receipt by CAR. A grant of authority continues until revoked by the
agent with notice to CAR.
Name - Print full name of agent as licensed
Title
_________________________________________
Signature
(Completed and signed forms may be faxed to the Residual Market Service Department at 617-880-7298).
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Massachusetts Authorization to Certify Motor Vehicle Insurance Coverage Form