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2. PROPERTY AND CASUALTY MARKET ASSISTANCE PROGRAM
4. Company Name*
5. NAIC Code*
7. Company Representative:
8. First Name*
9. Last Name*
11. Address1*
13. Address2
15. City*
16. State*
17. Zip*
19. Email Address*
20. Fax Number
21. Phone Number*
23. I have been properly authorized to enroll my company in the Market Assistance program. *

    1. Agree
    2. Disagree
25. By completing and submitting this form, the Company agrees as follows:
    
    1. Company will not use the applicants’ information or any other information obtained via participation in this program for any purpose other than reviewing for eligibility, quoting and/or binding insurance coverage.
    
    2. Company agrees not to disseminate, sell, disclose, publicize or otherwise distribute applicants’ personal financial or health information, or any other personal information, for any purpose whatsoever without the express written consent of the applicant.
    
    3. Company acknowledges and agrees that it is not a partner, business associate, employee, or contractor of the South Carolina Department of Insurance (the “Department”). Company is an independent contractor. The Department shall not be held liable for any acts, errors or omissions committed by the Company, its employees, contractors, successors or assigns and agrees to indemnify and hold the South Carolina Department of Insurance harmless from any and all liability resulting from its participation in this program.
    
    4. Participation in this program does not guarantee that applicants may or will purchase insurance coverage. The Department does not warrant the accuracy of the information submitted by the applicants.
    
    5. This constitutes the entire agreement between the parties regarding participation in this program. Jurisdiction of any dispute involving participation in this program shall be vested in the courts of Richland County, State of South Carolina.
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27. 1. Receive an email copy of this form.
28. Email address

    This field is not part of the form submission.

29. Submit

* indicates a required field