Thank-you for taking time to complete our secure on-line Agent Licensing and User Setup form. This information will enable us to set up your agency more quickly.

If you have more than 4 users to set-up, enter the information for the first 4 users, click "Submit", and then reopen a new form and continue entering the information for the remainder of your users.

Please contact our Marketing Support Team at: 866-300-6433, ext. 6599, if you have any questions.

Agency Name:
Address:
City:		State: Zip:
What is the return check fee charged by your bank when an insured's check is NSF? (Documentation is required for your file.)
Is User 1 a licensed agent?		YES NO (If no, skip licensing fields)
First Name1:		Last Name1:
Home Address1:
City1:		State1: Zip1:
Agent's Email address1:
Agent License #1:		License Expiration Date1:
Social Security #1:		Date of Birth1:
Should User 1 have access to view commission information?	*	YES NO
Please attach a scanned copy of User 1's Agent License:
Is User 2 a licensed agent?		YES NO (If no, skip licensing fields)
First Name2:		Last Name2:
Home Address2:
City2:		State2: Zip2:
Agent's Email Address2:
Agent License #2:		License Expiration Date2:
Social Security #2:		Date of Birth2:
Should User 2 have access to view commission information?		YES NO
Please attach a scanned copy of User 2's Agent License:
Is User 3 a licensed agent?		YES NO (If no, skip licensing fields)
First Name3:		Last Name3:
Home Address3:
City3:		State3: Zip3:
Agent's Email Address3:
Agent License #3:		License Expiration Date3:
Social Security #3:		Date of Birth3:
Should User 3 have access to view commission information?		YES NO
Please attach a scanned copy of User 3's Agent License:
Is User 4 a licensed agent?		YES NO (If no, skip licensing fields)
First Name4:		Last Name4:
Home Address4:
City4:		State4: Zip4:
Agent's Email Address4:
Agent License #4:		License Expiration Date4:
Social Security #4:		Date of Birth4:
Should User 4 have access to view commission information?		YES NO
Please attach a scanned copy of User 4's Agent License:
Comments: