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The Rough Notes Company, Inc., Circulation Department, 11690 Technology Drive, Carmel, IN 46032-5600

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OR click Print and fax the form to 800/321-1909.

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Name Date
Company Name **Title
Address
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**E-mail

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*We must have an answer to question #1 to process your request for a free subscription.
1. WHAT IS YOUR PRIMARY BUSINESS CATEGORY?*
(check one)

AGENTS, BROKERS AND LIFE GENERAL AGENTS/MANAGERS
01 Primarily selling Property/Casualty Insurance
02 Primarily selling Life/Health Insurance
03 Life General Agents and Managers
INSURANCE COMPANY PERSONNEL
A. Primarily Life, Health & Benefits
04 Health, Life & Benefits Home Office Personnel
05 Regional and Branch office personnel
B. Primarily Property/Casualty Insurance
06 Home Office Personnel
07 Regional and Branch office personnel
CORPORATE INSURANCE RISK MANAGERS AND BUYERS
OF INSURANCE
08 Property/Casualty Insurance
09 Employee Benefit Plan
10 Both Property/Casualty Insurance and Employee Benefit Plan
11 Life/Health Consulting Actuaries; Pension Consultants; Consulting Actuaries; Independent Claim Adjusters; Engineering and Inspections Services; Government Agencies, including Rating Bureaus and States Insurance Departments; Schools; Professional Associations and their related conference attendees; Attorneys; Financial and Banking Officials; Libraries; Customers for Rough Notes Company’s insurance agency technical reference services, forms and property casualty insurance licensing courses
2. WHAT IS YOUR TITLE? (check one)

AA. CORPORATE AND FINANCIAL MANAGEMENT
Chairman, CEO, President, Principal, Partner, Owner, Vice President,
Treasurer, Corporate Secretary, Director or Managers of Finance,
Controller, or Budget Director

BB. SUPERVISORY MANAGEMENT
Manager, General Manager, Supervisor, or Department Head
CC. MARKETING/SALES
Director or Manager of Advertising, Communications, Marketing Promotion, Agents, Brokers, Producers, Underwriter, or Sales
DD. OTHER TITLE (Please Specify)

3. ARE THERE OTHER PERSONS IN YOUR OFFICE WHO WOULD LIKE TO SUBSCRIBE TO THIS MAGAZINE?
Name Title
Name Title

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