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LB Connect Agency Application

Please fill out the form below to register for your LB Connect Agency Account.  

Agency Information
Agency:
Address:
 
City:
State:
ZIP:
Primary Contact Information
Position:
First Name:
M.I.:
Last Name:
Office Phone: ext. (xxx-xxx-xxxx)
Office Fax: (xxx-xxx-xxxx)
Email:

237 Main Street, Suite 1500    Buffalo, New York 14203-2720    ph: (716) 849-2626    email us