Please complete the below form with your refund address and contact information for the SERFF Block.

 

* 1. SERFF Instance Name (This can be found in the top right corner of SERFF when logged in):

* 2. Customer ID/Number (can be found on the billing tab in SERFF):

* 3. Refund Address Information:

* 4. In case we have questions regarding the above refund information, please fill out your contact information:

Questions? Please contact serffbilling@naic.org or 816-783-8787.

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