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| Commission Password Request |
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| Agents can view commission statements
online via Mendota's website (http://www.mendota-insurance.com). |
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| You will be able to access
your statements by selecting "My Account" from the
agent home page. The option is called "Commissions
Statement". |
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| For access, please complete this form
and return it to Mendota Insurance Company. |
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A few items to consider
when selecting your password: |
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Your password is case sensitive.
Be sure to print the password below, with any characters or numbers, EXACTLY
as you want it to appear (Preferably without spaces). |
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For your own security,
choose a different password than your initial sign-on. |
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Please send the completed
form to: |
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Mendota Insurance
Company |
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Attn: Finance |
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3343 Perimeter Hill Dr., Suite 214 |
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Nashville, TN 37211 |
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(or fax form to
952-656-9860) |
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| Agent Name:
____________________________________________ |
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| Agent Number: ___
___ ___ ___ ___ ___ ___ ___ ___ |
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| Password:
________________________________ |
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| Agent Phone Number:
________________________________ |
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| _________________________________________ |
____________________
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| (Signature of Principal) |
Date |
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| Access to the Commission
Statement on-line will be available 24 hours after the completed form has been
received in our
office. | |