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Farmers Agency Code: (Your code is your six digit Farmers agent code without the commission series) |
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| First Name: | |
| Last Name: | |
| Farmers Agent Email Address: | |
| Street Address: | |
| City: | |
| State: | |
| Zip Code: | |
| Phone: | |
| Fax: | |
| By checking this box I certify that I am currently a licensed insurance agent of Farmers Insurance. | |