50 Ill. Adm. Code 3113.EXHIBIT A
A Consent and Authorization Form
Section 3113
Section 3113.EXHIBIT A Consent
and Authorization Form
I
hereby give
written (or)
principal
licensee
permission and authorization to
place on deposit with any Federal or State chartered bank(s) money which
represents premium to be held or held on my behalf pursuant to 50 Ill. Adm.
Code 3113 for interest or income producing purposes. I further waive any right
to ownership in any interest or revenue produced from this deposit.
I agree and consent to the
above
principal
licensee
Date: