First Insurance Company of Hawaii, LTD

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By completing and submitting this form, you, the agent, are giving First Insurance Company of Hawaii permission to contact the policyholder directly regarding First Insurance Company of Hawaii services, with the understanding that you will be included on all correspondence only if your contact information is submitted on this form.

If you have questions regarding this form, please contact RSMOnline@ficoh.com.

Agent Information

First Name *

Last Name *

Brokerage *

Email Address *

Telephone * (eg. 8085551234)

Policy Holder Information

Company Name *

Main Contact

First Name *

Last Name *

Email Address *

Telephone * (eg. 8085551234)

Check the title that best describes the main contact: *

CEO
CFO
COO
Employee Health Representative
Human Resource Manager
Risk Manager
Other

Main Contact Title "Other"

Enter Word or Number Verification in box below *

Contact Permission Form

Agent Information

Policy Holder Information