"hereby submits that he/she is:" or, Section 1: Please enter the name of the Broker Section 1(C): Name of the Risk Purchasing Group Address of the Risk Purchasing Group Check if Employee (E) or Agent (A) Full Name of Admitted Company First & Last Name of Company Representative Telephone Number "( ) - " or Online Declination Website Month, Year of Declination "MM/YYYY" One or more lines of address information Name of the city Country Name