Carrier/Broker Code Request

Before submitting this request, please make sure that the client does not already exist in our system by searching for it in Epic.

Your Name

Company To Add

Is this an insurance Carrier?

YesNo

Type of Broker/Company

Wholesaler or Program - intermediary that places business for usReceivable - places business w/ us (often through programs) that continues to service and bill that client for the policyExternal Producer - Non-Employee or entity that brings in business that we will be servicing and billing directlyNon-Insurance Provider - a company that sells a product to our clients other than insurance (e.g. FSA plans, discount cards, etc.)

Type of Carrier

Issuing Company - This is the paper on which a policy is issued Billing Company - A carrier to who we pay commissions

Issuing Company Specific Data

Each Issuing Company must be verified on AM Best before it can be added.

AM Best #

Are they typically a Non-Admitted Surplus Lines Carrier?

YesNo

Broker Specific Data

Accounting needs a completed W9 form for each broker that will be receiving commissions. A blank version can be downloaded from the IRS website.

Broker's W9

For compliance purposes, we will also need a signed sub-producer agreement, resident broker's license and E&O certificate.

Signed Sub-Producer Agmt.

Brokers' License

E&O Certificate

Broker agreement in place?

Address

Phone

Website

Bill Mode

AgencyDirect

Commission Arrangement

Additional Instructions

Contact Information