Alabama Agency Information Form
Processing
Agency Information
Agency Legal Entity Name (As it appears on line 1 of your W9)**
Agency dba (If applicable, as it appears on line 2 of your W9)**
Agency FEIN**
Agency NODE ID:**
Email address to receive Personal Lines policy notifications**
Email address to receive Cajun UW updates **
Agency Phone Number**
Agency Fax Number**
Agency Website**
Physical Address
Address**
City**
Zip**
State**
Parrish**
Mailing Address
Is the agency mailing address the same as the physical address above? If no, please complete the section below**
Address**
City**
Zip**
State**
Parrish**
Errors & Ommissions
E&O Carrier Name**
E&O Policy Number**
E&O Expiration Date (MM/DD/YY) **
Agency Principal
Name**
License Number**
Email**
NPN Number**
Agency Owners and Officers
Owner NameOwner/Officer TitleOwner Email AddressOwner Street AddressOwner CityOwner StateOwner Zipcode
Current Carrier Information
Carrier NameHomeHome Loss/RatioPersonal AutoAuto Loss/RatioCommercialCommercial Loss/RatioFloodFlood Loss/Ratio
Social Media Presence
Facebook
LinkedIn
Twitter
Agency Management System
Vendor**
Version**
IVANS Y Acct. #**
Agency Marketing Strategy
Local (within 5 miles)
Regional (Home County and surrounding Counties)
Entire State
Agency Book
Personal Lines**
Commercial Lines**
New Homeowners Policies
Average# of New Homeowners Policies written per Month:**
Agency Employee
Number of Employees in the Agency:**
Agency Contact Information
Contact NameContact TitleContact DepartmentContact PhoneContact Email Address
Banking Information
Financial Institution**
ABA Transit/Routing Number**
Account Number**
Account Name**
Date of Signature**
Required Documents
W9 Form
License Copy
Agreement Terms
Agreement Terms must be viewed before submitting