ARAG PRODUCER APPLICATION8c17ad09-ce71-4618-9668... · 2020. 12. 15. · 1313 ARAG North America,...

of 3 Rev 11/20 100471© 2020 ARAG North America, Inc. | 800-888-1484 ext. 255 | [email protected]

ARAG PRODUCER APPLICATION

SECTION I – Appointing Agent Information Please fill out the following information as it appears on your state license and W-9. The information provided below must match in order to be paid commissions.

APPOINTING AGENT___________________________________________ _____ _________________________________________________ ________________FIRST NAME MI LAST NAME SUFFIX

_______________________________________________________________________________________________________________________EMAIL ADDRESS

___________________________________________________________________ _____________________________________________ADDRESS LINE 1 (STREET NAME) STATE IN WHICH YOU HOLD A RESIDENTIAL LICENSE

___________________________________________________________________ _____________________________________________ADDRESS LINE 2 (SUITE, APARTMENT NUMBER) NPN NUMBER

___________________________________________________________________ CITY, STATE, ZIP

___________________________________________________________________ COUNTY

____________________________ DATE OF BIRTH (MM/DD/YYYY)

____________________________ _______________________________SOCIAL-SECURITY NUMBER PHONE NUMBER

____________________________ _______________________________FAX NUMBER MOBILE NUMBER

PLEASE NOTE: ARAG® requires Property and Casualty or Legal Expenses licenses in most states. An ARAG representative will discuss with you what license is required.

SECTION II – Consent to Background Check

I, __________________________________, hereby attest that I am authorized to provide the information on this form and that it is true and accurate to the best of my knowledge. I understand that ARAG will verify all or part of this information which may include an inquiry into my criminal history, and/or prior employment, and/or prior relationships with companies with which I have worked as an Agent/Producer and I consent to such inquiry. I authorize release of such information as may be necessary to verify the information I have provided on this form.

I release and hold harmless from all liability any individual or entity requesting or supplying information with respect to my application to be appointed as an agent/producer. My signature below also certifies that I have not been convicted of any criminal felony involving dishonesty or breach of trust nor an offense under Section 1033 of the Violent Crime and Law Enforcement Act of 1994. I understand submission of this application is not a guarantee of acceptance and I will be notified by ARAG as to whether my application has been accepted.

__________________________________________________________________________ _______________________________________APPLICANT’S SIGNATURE DATE

PLEASE INDICATE THE LICENSE LINE OF AUTHORITY AND LICENSE NUMBER.


ARAG PRODUCER APPLICATION ARAG LEGAL INSURANCE

SECTION III – Licensing Contact and Agency Information

_______________________________________________________________________________________________________________________AGENCY NAME

___________________________________________________________________ _____________________________________________PRIMARY LICENSING CONTACT (FIRST NAME) PRIMARY LICENSING CONTACT (LAST NAME)

_______________________________________________________________________________________________________________________ PRIMARY LICENSING CONTACT (E-MAIL ADDRESS)

_______________________________________________________________________________________________________________________ WEBSITE URL

___________________________________________________________________ _____________________________________________ADDRESS LINE 1 (STREET NAME) STATE IN WHICH YOU HOLD A RESIDENTIAL LICENSE

___________________________________________________________________ _____________________________________________ADDRESS LINE 2 (SUITE, APARTMENT NUMBER) NPN NUMBER

___________________________________________________________________ CITY, STATE, ZIP

___________________________________________________________________ COUNTY

____________________________ _______________________________TAX IDENTIFICATION NUMBER (TIN) PHONE NUMBER

____________________________ FAX NUMBER

COMMISSION CHECKS SHOULD BE MADE PAYABLE TO: (CHECK ONE)

AGENT AGENCY

SECTION IV – Payment Options Choose ONE payment method below. If a payment method is not chosen, payment will be made monthly by paper check.

1. ELECTRONIC FUNDS TRANSFER

If you choose this method of payment, please include a VOIDED CHECK or company details on bank letterhead.

_______________________________________________________________________________________________________________________COMPANY NAME

_______________________________________________________________________________________________________________________NAME ON ACCOUNT (IF DIFFERENT THAN COMPANY NAME)

_______________________________________________________________________________________________________________________FINANCIAL INSTITUTION NAME

______________________________________________ ______________________________________________________________________ROUTING/TRANSIT NUMBER ACCOUNT NUMBER

_______________________________________________________________________________________________________________________EMAIL REQUIRED FOR ELECTRONIC REMITTANCE

__________________________________________________ _________________________ _______________________________________AUTHORIZED CONTACT PHONE NUMBER EMAIL IF DIFFERENT FROM ABOVE

__________________________________________________ _________________________ _______________________________________BANK CONTACT PHONE NUMBER EMAIL IF DIFFERENT FROM ABOVE

If I choose Electronic Funds Transfer, my signature below confirms authorization for ARAG or its affiliates to initiate electronic credit entries to my account for payment of commissions. Should ARAG enter more money into my account than I am entitled to receive, I authorize ARAG to withhold such amount from a further credit entry. This authority will remain in effect until I notify ARAG of a change in my account or cancel it in writing.

__________________________________________________________________________ _______________________________________APPLICANT’S SIGNATURE DATE

2. PAPER CHECK

PLEASE INDICATE THE LICENSE LINE OF AUTHORITY AND LICENSE NUMBER.

PLEASE NOTE: ARAG requires Property and Casualty or Legal Expenses licenses in most states. An ARAG representative will discuss with you what license is required.


ARAG PRODUCER APPLICATION ARAG LEGAL INSURANCE

SECTION V – Request for Taxpayer Identification Number and Certification This section provides all pertinent IRS W-9 information necessary for the completion of 1099 forms. You can substitute this section with your official W9 form.

AGENCY CONTACT_______________________________________________________________________________________________________________________ NAME (AS SHOWN ON YOUR INCOME TAX RETURN)

_______________________________________________________________________________________________________________________ BUSINESS NAME, IF DIFFERENT FROM ABOVE

CHECK APPROPRIATE BOX

INDIVIDUAL/SOLE PROPRIETOR CORPORATION PARTNERSHIP

LIMITED LIABILITY COMPANY. (ENTER TAX CLASSIFICATION (D= DISREGARDED ENTITY, C= CORPORATE, P=PARTNERSHIP) _____

OTHER ______________________________________________________________________________________________________________________________________________

CHECK HERE IF EXEMPT PAYEE

___________________________________________________________________ ADDRESS LINE 1 (STREET NAME)

___________________________________________________________________ ADDRESS LINE 2 (SUITE, APARTMENT NUMBER)

___________________________________________________________________ ____________________________________CITY, STATE, ZIP TAX IDENTIFICATION NUMBER (TIN)

OR

___________________________________________________________________ ____________________________________COUNTY EMPLOYER IDENTIFICATION NUMBER

IRS CertificationUnder penalties of perjury, I certify that:

1. The number shown on this form is my correct taxpayer identification number (or I am waiting for a number to be issued to me), and

2. I am not subject to backup withholding because: (a) I am exempt from backup withholding, or (b) I have not been notified by the Internal Revenue Service (IRS) that I am subject to backup withholding as a result of a failure to report all interest of dividends, or (c) the IRS has notified me that I am no longer subject to backup withholding, and

3. I am a U.S. citizen or other U.S. person (defined in the instructions).

Certification instructions. You must cross out item 2 above if you have been notified by the IRS that you are currently subject to backup withholding because you have failed to report all interest and dividends on your tax return. For real estate transactions, item 2 does not apply. For mortgage interest paid, acquisition or abandonment of secured prop-erty, cancellation of debt, contributions to an individual retirement arrangement (IRA), and generally, payments other than interest and dividends, you are not required to sign the Certification, but you must provide your correct TIN.

The Internal Revenue Service does not require your consent to any provision of this document other than the certifications required to avoid backup withholding.

__________________________________________________________________________ _______________________________________SIGNATURE OF U.S. PERSON DATE

Please submit the following by email to [email protected] or fax to 515-246-8710:

Application

Errors & Omissions

Copy of Required License (if applicable)

Voided check or bank letter (if applicable)

W9 (if applicable)

Signed Producer Agreement

Broker of Record Letter

TAXPAYER IDENTIFICATION NUMBER (TIN)

The TIN provided must match the name given in this section to avoid backup withholding. For individuals, this is your Social Security Number (SSN). For other entities, it is your Employer Identification Number (EIN). If you do not have a number, or need assistance, please visit www.irs.gov.N

FIRST NAME: MI: LAST NAME: SUFFIX: EMAIL ADDRESS: ADDRESS LINE 1 STREET NAME: ADDRESS LINE 2 SUITE APARTMENT NUMBER: CITY STATE ZIP: COUNTY: DATE OF BIRTH MMDDYYYY: SOCIALSECURITY NUMBER: PHONE NUMBER: FAX NUMBER: MOBILE NUMBER: STATE IN WHICH YOU HOLD A RESIDENTIAL LICENSE: NPN NUMBER: PLEASE INDICATE THE LICENSE LINE OF AUTHORITY AND LICENSE NUMBER: it is true and accurate to the best of my knowledge I understand that ARAG will verify all or part of this information which: DATE: AGENCY NAME: PRIMARY LICENSING CONTACT FIRST NAME: PRIMARY LICENSING CONTACT LAST NAME: PRIMARY LICENSING CONTACT EMAIL ADDRESS: WEBSITE URL: ADDRESS LINE 1 STREET NAME_2: ADDRESS LINE 2 SUITE APARTMENT NUMBER_2: CITY STATE ZIP_2: COUNTY_2: TAX IDENTIFICATION NUMBER TIN: PHONE NUMBER_2: FAX NUMBER_2: STATE IN WHICH YOU HOLD A RESIDENTIAL LICENSE_2: NPN NUMBER_2: PLEASE INDICATE THE LICENSE LINE OF AUTHORITY AND LICENSE NUMBER 2: COMPANY NAME: NAME ON ACCOUNT IF DIFFERENT THAN COMPANY NAME: FINANCIAL INSTITUTION NAME: ROUTINGTRANSIT NUMBER: ACCOUNT NUMBER: EMAIL REQUIRED FOR ELECTRONIC REMITTANCE: AUTHORIZED CONTACT: PHONE NUMBER_3: EMAIL IF DIFFERENT FROM ABOVE: BANK CONTACT: PHONE NUMBER_4: EMAIL IF DIFFERENT FROM ABOVE_2: DATE_2: Payment Options: OffCommission Checks: OffNAME AS SHOWN ON YOUR INCOME TAX RETURN: BUSINESS NAME IF DIFFERENT FROM ABOVE: INDIVIDUALSOLE PROPRIETOR: OffCORPORATION: OffPARTNERSHIP: OffLIMITED LIABILITY COMPANY ENTER TAX CLASSIFICATION DDISREGARDED ENTITY C CORPORATE PPARTNERSHIP: OffLimited Liability: [ ]OTHER: Offother2: CHECK HERE IF EXEMPT PAYEE: OffADDRESS LINE 1 STREET NAME_3: ADDRESS LINE 2 SUITE APARTMENT NUMBER_3: CITY STATE ZIP_3: COUNTY_3: TAX IDENTIFICATION NUMBER TIN_2: EMPLOYER IDENTIFICATION NUMBER: DATE_3: Application: OffErrors Omissions: OffCopy of Required License if applicable: OffVoided check or bank letter if applicable: OffW9 if applicable: OffSigned Producer Agreement: OffBroker of Record Letter: OffPrint: Email: Reset:

ARAG PRODUCER APPLICATION8c17ad09-ce71-4618-9668... · 2020. 12. 15. · 1313 ARAG North America,...

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Transcript of ARAG PRODUCER APPLICATION8c17ad09-ce71-4618-9668... · 2020. 12. 15. · 1313 ARAG North America,...