Affiliation Form 202B Revised July 2021
STATE OF NEW MEXICO – OFFICE OF SUPERINTENDENT OF INSURANCE (OSI)
PRODUCER LICENSING BUREAU
Business Entity Affiliation Form
Business Entity Federal Id Number ___________________________________License Number __________
Business Entity Name______________________________________________________________________
Address _____________________________________City _____________________State Zip____________
Contact Person ___________________________________________ Telephone No. ___________________
Email Address________________________________ Check if Entity license is Pending application ____
Notice is hereby given that effective from the date shown on this notice, the designated business entity hereby affiliates
the licensee(s) named herein to act as its affiliate.
Affiliation fee is $20.00 per affiliate/per license type. We do not
affiliate agencies. Please list only individual agents.
Checks must be made payable to OSI.
12345 – Independent Adjuster
AFFILIATIONS ARE RENEWED ANNUALLY AND MUST BE MAINTAINED FOR THE LIFE OF THE
BUSINESS ENTITY LICENSE
Please have only 6 affiliations per form, we will not accept “attached spreadsheets”
Total affiliations ____________ $20.00 per affiliate = $___________
Check/ Money Order _____ ACH Credit __________ or Wire __________
Signature must be that of an officer of the business entity or a person authorized by the business entity to sign
on behalf of the business entity. Electronic payment may take up to 5 business days to be received by OSI.
Official Title_____________ Signature_________________________ Date________________
For electronic payments: Once you have made payment via ACH Credit or Wire, please email this form to
agents.licensing@state.nm.us
Producer Licensing
1120 Paseo De Peralta
Santa Fe, NM 87501
All filing fees are non-refundable or non-transferable, whether or not the application is processed. Per NMSA 59A-6-1
all fees are earned when paid and are not refundable.
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