TEXAS INSURANCE CHECKING OFFICE, INC.
TERRY PORTER / (512)444-9662 / 2801 South IH 35 (78741)DIRECTOR / FAX: (512) 326-7605 / P.O. BOX 15, AUSTIN, TEXAS 78767-0015
www.ticostat.com
Statistical Coding Agreement Form
FOR SERVICES TO BE PROVIDED BY
TEXAS INSURANCE CHECKING OFFICE, INC.
The undersigned insurer (Company) subscribes to the statistical coding services of the Texas Insurance Checking Office, Inc. (TICO) for coding/ statistical reporting services for the Company in Texas for the following lines of insurance:
(CHECK ALL LINES REQUESTED)
COMMERCIAL
/PREMIUM
/LOSS
/ RESIDENTIAL /PREMIUM
/LOSS
PROPERTY
/ / / / /HOMEOWNERS
/ / / /LIABILITY
/ / / / /DWELLING
/ / / /BUSINESSOWNERS
/ / / /AUTOMOBILE
/ / / /MISCELLANEOUS COMMERCIAL
/ / / /FIDELITY & SURETY
/ / / /MISCELLANEOUS PERSONAL
/ / / /FARM AND RANCH
/ / / /FARM AND RANCHOWNERS
/ / / /TICO will code all policies in accordance with Statistical Plans required by the Texas Department of Insurance and report to the designated statistical agent of the company. If the company reports commercial statistics by tape, TICO will edit, assist in error corrections and report (if requested).
The Company agrees to pay TICO within 30 days of receipt of an invoice for services furnished by TICO.
This Agreement shall remain in effect until terminated in writing. Notice of termination shall be sent to the other party by Fax or Certified Mail.
TICOAGRM-6/04
TEXAS INSURANCE CHECKING OFFICE, INC.
TERRY PORTER / (512)444-9662 / 2801 South IH 35 (78741)DIRECTOR / FAX: (512) 326-7605 / P.O. BOX 15, AUSTIN, TEXAS 78767-0015
www.ticostat.com
Signature /Name & Title
(Please print or type)
Date
TICOAGRM-6/04
TEXAS INSURANCE CHECKING OFFICE, INC.
TERRY PORTER / (512)444-9662 / 2801 South IH 35 (78741)DIRECTOR / FAX: (512) 326-7605 / P.O. BOX 15, AUSTIN, TEXAS 78767-0015
www.ticostat.com
List Name of Insurer(s) below: (Please print or type) NAIC #
TICOAGRM-6/04