National Crop Insurance Services   
  8900 Indian Creek Parkway Suite - 600    
  Overland Park, KS 66210-1567    
  Phone:   913-685-2767 - Fax: 913-685-3080  
NCIS Logo
 

MPCI Agent Change/Add Form

This form is to be used by companies' authorized personal do Add/Delete/Change AGENTS ONLY to our system.
Please do not use this form to add staff to our other website  secure areas.  There is a procedure for that and if you have any questions, please contact us about this procedure.

This form is to be submitted by an authorized staff of a Member Company only.

Insurance agents please go through your insurance companies for requests.

Please provide the following information:

Note: If you need more space for counties than this form allows, submit as many forms as it is necessary, but please fill in all the information every time you submit this form. If you have any question on how to fill this form, please e-mail webmaster.


Today's Date: Month: Day Year

Insurance Company*: 
Contact Name*:
Street address*:
PO Box#: 
City*:
State/Province*:
Zip/Postal code: 
Phone*:
E-Mail Address*: 

Change*
Add an Agent
            Delete an Agent         Other Change

Fill in Agent's Current Address: (So that we can find it in our system)
Agent Name*:  
Address 1*:    
Address 2:  
City, ST, Zip*:  
 

Fill in Agent's New Address: (Use above boxes if agency is not changing name or address)
Agent Name:
Address 1:
Address 2:  
City, ST, Zip:

Add/Delete Counties (choose one):             

(Please use 2-digits state codes and 3-digit county codes. FCIC Codes.)

ST#              All Counties

County#s(Separated by "," or "-":  (PLEASE USE COUNTY CODE NUMBER, NOT NAME)

ST#              All Counties
County#s(Separated by "," or "-":  (PLEASE USE COUNTY CODE NUMBER, NOT NAME)

ST#              All Counties
County#s(Separated by "," or "-":  (PLEASE USE COUNTY CODE NUMBER, NOT NAME)

ST#              All Counties
County#s(Separated by "," or "-":  (PLEASE USE COUNTY CODE NUMBER, NOT NAME)

 
PS: IF CHOOSING ONLINE, PLEASE PROVIDE:
CONTACT NAME;
TELEPHONE NUMBER AND
E-MAIL ADDRESS

FOR THE AGENCY, IN THE COMMENTS BOX BELOW. 
WE CANNOT SETUP THE AGENT WITHOUT THESE EXTRA INFORMATION.


Add Nursery CD/Books:
How Many Nursery CD/Books?


Comments:
 

* Security Question: 5 x 4=

*=REQUIRED FIELDS

Please do not use this form to submit requests for access to Main Website or the FTU.  Please read top message.


| Home | About NCIS | Search | NCIS Store | Products/Services | Events | Privacy | Other Links | Contact | PDF Files |
Any questions about this website, please contact the webmaster at NCIS.
Please read our 2014 National Crop Insurance Services