AGENT Onboarding Questionnaire

Pacific Crest Agent Information

We are here to help! If you have any questions, please call the licensing team at (208) 938-4197.
Legal Name*

First NameLast Name
Preferred Name

First NameLast Name
Have you changed your name in the past 5 years?

YesNo
Previous Name or Alias

First NameLast Name
Date of Birth*

MonthDayYear
Social Security Number*
What is your home address?*

Street Address

Street Address Line 2

CityState

Zip Code
How long have you lived at this address?
Contact Information

Please provide us with your contact information including the best way for clients and carriers to reach you during business hours.
What is your cell phone number?*
What is your office phone number?*
Can we provide your cell phone number to clients and carriers?

YesNo
What is the best phone number for clients and carriers to reach you during business hours?*
Office Fax Number
Do you have a voicemail system for your agency?

YesNo

Agency Information

Please provide us with your agency information. If you are unsure of what to list please list Unknown and we will discuss this during our Agency Discovery call.
Agency and/or Entity Name
Agency Name Include DBA or Fictitious Name if Applicable
Is this Entity registered with the Agency Operational State?

YesNo
Entity Federal Tax Classification

IndividualPartnershipLLC/LLPCorporationOther
FEIN or Tax ID Number
Please upload a W9. If you do not have a copy you can download a template from the IRS website.

Browse Files

Cancelof
Do you have an Agency License?

YesNo
Agency License Number
Please upload a copy of your Agency License.

Browse Files

Cancelof

Agency Location
Do you have an office location for your agency?*

YesNoNo, but I will have a location before opening my agencyOther
Agency Office Address*

Street Address

Street Address Line 2

CityState

Zip Code
Agency Location County
Do you work at this location?*

YesNo
What is the address of the location you work?

Street Address

Street Address Line 2

CityState

Zip Code
Location County
Do you receive mail at your office?*

YesNo
Agency Mailing Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Total Agency Staff

Pacific Crest Agent Questionnaire