The following form is to be used to submit to REPEG information to accompany distribution of a referral from an agent
of the company to another company. Please complete the form as fully as possible and fax, email or mail it to the office at: 884 Allen Dr., Northville, MI 48167
You can go ahead and forward it to an agent of your choice or you can ask our office to find an agent to contact the indiviual. In either case, this form should be submitted.