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National Crop Insurance Services 

8900 Indian Creek Parkway, Suite 600
Overland Park, KS 66210
office (913) 685-2767
fax (913) 685-3080

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MPCI Agent Change/Add Form

This form is to be used by our member companies' authorized personal only to 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.

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 IN THE COMMENTS BOX BELOW THE AGENCY'S :
CONTACT NAME:
TELEPHONE NUMBER:
AND
CONTACT E-MAIL ADDRESS:
 

WE CANNOT SETUP THE AGENT WITHOUT THE EXTRA INFORMATION.

Add Nursery CD-Software/PDF Books:

How Many Nursery CD:

 Comments:
 

* Security Question: 4 + 4=

*=REQUIRED FIELDS

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