Demographic Information. Agency or Check here if you are NOT working with an agency Producer Name (Registered with IRS) (Legal Entity Name) (DBA Name—Optional) TIN -- Taxpayer Type: Corp Sole Prop. LLC LLP Other Entity Phone # ( ) - Ext. Fax # ( ) - Email Mail. Addr. c/o (Optional) (Street or PO Box) (City) (State) (ZIP) Bus. Addr. (Street—must be street address, no PO boxes) (City) (State) (ZIP) Licensing/Commissions Contact Name (Optional) Phone # ( ) - Ext. Fax # ( ) - Email (If Yes, please complete the Compensation Assignment Form for the assignment to be effective.) Yes No
Appears in 5 contracts
Samples: Agent/Agency Agreement, Agent/Agency Agreement, Agent/Agency Agreement