Broker Agreement Form

Transcription

1 Broker Agreement Form To begin working with American Collectors Insurance, please read and complete the following agreement. Please provide the following information: Agency Name Agency Mailing Address: Federal T ax I D Number Agency Phone Number Agency Fax Number Name & Title of Primary Contact Address of Primary Contact By checking the box and signing below, you acknowledge and agree to the following terms: I hereby acknowledge that no contractual relationship exists between my brokerage/agency and American Collectors Insurance. I understand that my brokerage/agency has no binding authority or appointment of any kind for any risk or risk situation, and that risks submitted to American Collectors by myself, my partners, or employees are not bound unless and until American Collectors Insurance advises in writing that they are bound. I warrant that the resident & non-resident license(s) and Errors and Omissions policy of my brokerage/agency will remain in force throughout the time we place and have business in force with American Collectors Insurance. I AGREE to enter into this Broker Agreement electronically via the Internet. I consent to be notified by at the indicated address regarding this agreement. I acknowledge that whenever my signature or consent is required in connection with this agreement, my electronic signature or consent shall be deemed to be sufficient and acceptable under any applicable state or federal electronic signature or transaction regulations, and such electronic signature or consent shall constitute my actual acceptance of the terms that I agree to. (Please type the full name of person authorized to sign on behalf of the agency/brokerage) Date To submit this agreement, simply this completed form to us with a copy of the following documents: Current E&O declarations page Current agency resident & non-resident license(s) Fax: brokerupdate@americancollectors.com Mailing Address: 496 Kings Highway North, Cherry Hill, NJ

2 Direct Deposit Registration Form Get commission quicker and easier by signing up for Direct Deposit today: 1. It s fast. No need to wait for the mail or stand in line at the bank! 2. It s safe and reliable. You will receive a monthly when the deposit has been made. 3. It s simple. You can view and print your commission statement online. 4. It s environmentally friendly. Go green! To sign up for Direct Deposit of commissions, complete and this form to brokerupdate@americancollectors.com. Automated Clearing House (ACH) Authorization Agreement Producer Code Bank City, State, Zip Code Receiving Bank Name Account Type (Select One): Checking Savings ABA Routing Transit Number Account Number Name on Account Address for Direct Deposit Notification By checking the box next to each statement and signing below, you acknowledge and agree to the following terms: I authorize American Collectors Insurance to initiate commission deposits to my brokerage/agency account at the financial institution indicated below. I understand this authorization is to remain in full force and effect until American Collectors Insurance has received written notification from my brokerage/agency of its termination in such time and in such manner as to afford them a reasonable opportunity to act on it. I AGREE to enter into this Automated Clearing House Authorization Agreement electronically via the Internet. I consent to be notified by at the indicated address regarding this agreement. I acknowledge that whenever my signature or consent is required in connection with this agreement, my electronic signature or consent shall be deemed to be sufficient and acceptable under any applicable state or federal electronic signature or transaction regulations, and such electronic signature or consent shall constitute my actual acceptance of the terms that I agree to. (Please type the full name of person authorized to sign on behalf of the agency/brokerage) Date Note: Please contact American Collectors Insurance if the above information changes at any time. You can us at brokerupdate@americancollectors.com or call

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