Producer Application

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1 5300 Adolfo Road, Suite 200 Camarillo, California United with you on the road Marketing NAIC Number Fax Unidos contigo en el camino Producer Application Corporate Information Agency Name: DBA: Number of Offices: Agency License # : Principal Address: Mailing Address (if different from above): Contact Person: Telephone: Fax: Website: Please list number of agents: Customer Service Reps: Year Established: Ownership Personnel Please list all persons having an ownership interest in the agency (attach additional sheet if necessary). Agency Owner: Social Security Number: Home Address: Home Telephone: What rating system do you use? What Management system do you use? Cellular: Fax: Please provide account number. Account Number Would you like to set up download through IVANS? Yes No Account Number For all additional locations, please provide all branch office locations, phone, fax, & contact. Also indicate if you prefer separate producer codes for each location. Yes No Location 2: Location 3: Location 4: Location 5: Business distribution: Auto % Home % Commercial % Total annual volume Current Year: $ Prior Year $ 2 Yrs Prior $ 3 Yrs Prior $ Average monthly new business applications: Auto Home Commercial

2 Please list your five highest volume companies: Company Date Appointed Loss Ratio % Trust Account Information All down payments are swept through your Trust account. In order to be considered for an appointment you must have a designated Trust account. (per Chapter 5, Article 12, Section 1734 of the Insurance Code. See attached regulations.) I, the undersigned, hereby authorize Alliance United Insurance Services, Inc. to initiate debit entries electronically, by paper means, or by any other commercially accepted method, to my above referenced bank account for any amounts due, when they are due. I hereby authorize my financial institution to debit the same such account. I understand that if the transaction is rejected/returned by your financial institution, for any reason (including NSF), a $25.00 return check fee will be due, and added to your balance. I further grant permission to debit the return item fee electronically in same manner as payment. Print Name: Signature: Date: Bank Name: Routing Number: Account Number: Operating Account Information Commissions are directly deposited to your account. ACH is a requirement of doing business with Alliance United. In order to be considered for an appointment you must have a designated Operating account (separate from Trust Account) for transferring of Commission Monies from AUIS (deposited to agent s account) : Bank Name: Routing Number: Account Number: Please provide the following items with the completed application: Copy of Errors & Omissions Copy of Broker Bond Copy of Agency and/or all current producer licenses Completed W9 Copy of voided check from your Trust Account Copy of voided check from your Operating Account Production & Loss Reports for the last 2-3 years from your 3 highest volume companies A résumé regarding your background & insurance history if you are new in business I certify that the information provided is true and accurate to the best of my knowledge. I authorize Alliance United to investigate my background, including but not limited to obtaining consumer credit reports, driving record history, and/or criminal record history. I understand that Alliance United will keep this information confidential, and will not share with others, except as required by law. I understand that by completing this application Alliance United Insurance Services is under no obligation to appoint me as a broker. Print Name: Signature: Date: Please submit this application via upload, or fax along with all additional required documents to (fax) ; ( )

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4 Marketing NAIC Number Fax Adolfo Road, Suite 200 Camarillo, California Agency Commission Direct Deposit Electronic Funds Transfer Authorization for Commission Payments I hereby authorize Alliance united, through any of its affiliated companies, to initiate credit entries for Agent/Broker commission payments and to initiate, if necessary, debit entries and adjustments for any such credit entries in error to Agent/Broker s account(s) and the Agent/Broker s Bank to credit and/or debit the same to such accounts. Any disputes regarding the amount debited or credited from Agent/Broker s account for commissions shall be resolved by the parties involved as soon as practical after Alliance United receives notice of such dispute. This authorization is to remain in force until Alliance United has received written authorization from Agent/Broker of its termination or change. Producer Code (s): Broker Name: Contact Name: Address: Authorized Signature: Date: Financial Institution: Branch City: State: Routing #: Account #: Checking Savings Attach Voided Check Here Why do I need to provide a voided check? A voided check is necessary for verification of your Bank Account and APA/ Routing Number I don t use checks with this account. What do I do? If a pre-printed check is not available to send with this form. Please provide a document from your bank listing the account and routing numbers. (NOT: Deposit slips or temporary checks cannot be accepted as verification) Please fax to (800) Or to:

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