AIA Producer Application

Full Name*

First NameLast Name

Agency Name

Home Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Agency Address*

Street Address

Street Address Line 2

CityState

Zip Code

Phone Number*

Area CodePhone Number

E-mail

Social Security Number*

Birth Date*

Date

Driver's License*

Years in the Business

Do you have a current bail license? (Please provide license number)

If yes, what state are you licensed in?

Street Address

Street Address Line 2

Do you write through a General Agent?

Current Surety(ies)

How much liability do you write in a year?

How much of this liability do you anticipate writing with AIA?

BUF Balance

How did you hear about AIA?

Has any disciplinary action, including but not limited to, refusal, suspension, revocation, ever been taken by any regulatory agency in any state against you or any business with which you have been directly connected?

YesNo

Have you ever been convicted of, pleaded guilty or no contest to any misdemeanor or felonty or currently have pending misdemeanor or felony charges filed against you?

YesNo

In connection with your application for a producer underwriting agreement (“Agreement”) with Allegheny Casualty Company and/or International Fidelity Insurance Company, you understand and agree that AIA Holdings, Inc. (“AIA”) may obtain credit, consumer or investigative reports (“Reports”) concerning you and/or your business entity(ies) (“you/your”). Such reports would including information about your character, general reputation, personal characteristics and mode of living, finances, credit history/scores, employment records, education, qualifications, criminal records, driving records, credentials, and/or credit and indebtedness, and may involve personal interviews with sources such as supervisors, friends, neighbors, associates, public record or various federal, state, or local agencies.

By "Checking Agree" below, you hereby authorize the AIA to obtain such Reports from any such agency/entity which provides such reports. You further authorize any ongoing procurement of such Reports at any time during the term of the Agreement, if any.*

I agree

Date*

Date

For Maine Applicants Only

Upon request, you will be informed whether or not an investigative consumer report was requested, and if such a report was requested, the name and address of the consumer reporting agency furnishing the report. You may request and receive from us, within 5 business days of our receipt of your request, the name, address and telephone number of the nearest unit designated to handle inquiries for the consumer reporting agency issuing an investigative consumer report concerning you. You also have the right, under Maine law, to request and promptly receive from all such agencies copies of any reports.

For New York Applicants Only

You have the right, upon written request, to be informed of whether or not a consumer report was requested. If a consumer report is requested, you will be provided with the name and address of the consumer reporting agency furnishing the report.

For Washington Applicants Only

If we request an investigative consumer report, you have the right, upon written request made within a reasonable period of time, to receive from us a complete and accurate disclosure of the nature and scope of the investigation. You have the right to request from the consumer reporting agency a summary of your rights and remedies under state law.

For California, Minnesota or Oklahoma applicants only: A consumer credit report will be obtained through Business Information Group, Inc. (BIG), P.O. Box 541, Southampton, PA, 18966 Telephone (800) 260-1680. www.bigreport.com.

Please send me a copy of the consumer report (if one is obtained)Please send me a copy of the investigative consumer reports (if one is obtained)

For California applicants only.

If you chose to receive a copy of the consumer report, it will be sent within three (3) days of the employer receiving a copy of the consumer report and you will receive a copy of the investigative consumer report within seven (7) days of the employer’s receipt of the report (unless you elected not to get a copy of the report). BIG’s privacy practices with respect to the preparation and processing of investigative consumer reports may be found at www.bigreport.com (link at bottom of page entitled, “Legal/Privacy”).

I waive my right to obtain a copy of the report

A financial statment must be completed in addition to filling out the above information: https://form.jotform.com/20111531257.