Common Contracts
2 similar Application Producer Agreement contracts
Appointment ChecklistApplication Producer Agreement β’ April 2nd, 2019
If you have multiple locations, please include a list with the address, phone number, email address, and associated banking of each location. Please advise if you prefer all commission checks and statements to be mailed to one location or paid directly to one account. If separate accounts are required, please include ACH forms (credit and sweep,) with a voided check for each location.
Application Producer Agreement Agency ACH Form (Sweep Acct) Copy of Voided Check (Sweep Acct) Agency Direct Deposit Form (Sweep Acct) Copy of Voided Check (Deposit Acct) Copy of E&O Dec page or BinderApplication Producer Agreement β’ April 2nd, 2019
Agency Name Year Established Telephone Number Physical Address(home office) City, State, Zip Fax Number Mailing Address (if Different) (include city, state and zip) E-Mail Address Agency Principal, Name and Title Home Address (include city, state, and zip) Date of Birth Previous Residence locations in the last 5 years Previous Agency Business locations in the last 5 years DO YOU CURRENTLY SUBSCRIBE TO A COMPARATIVE RATING SYSTEM? π Yes π No IF YES, PLEASE PROVIDE THE NAME OF THE RATING SYSTEM: Current E&O Carrier Expiration Date: Agency License # Expiration Agency NPN FEIN/Tax ID Policy Number Limits: Names of Licensed Individuals (List on separate sheet if necessary) National Producer # (NPN) Agent License # / Expiration Date of Birth Social Security #
