We have a separate contract for you to complete as an Acrisure agency. You do not need to continue completing this form. Please click the link below to complete the correct contract.
AUI Acrisure Agency Contract Form
EXCEPT AS OTHERWISE PROVIDED IN THIS AGREEMENT, NOTICES UNDER THIS AGREEMENT SHALL BE SENT TO THE FOLLOWING MAILING ADDRESS FOR THE AGENCY:
IN WITNESS WHEREOF, THE AGENCY AND AUI HAVE CAUSED THIS AGREEMENT TO BE EXECUTED FROM:
BETWEEN:
AND:
APPALACHIAN UNDERWRITERS, INC.
Robert J. Arowood
PRESIDENT
NOTE: WE CAN ONLY PAY YOUR AGENCY COMMISSION VIA ELECTRONIC FUNDS TRANSFER (EFT).
I/WE AUTHORIZE APPALACHIAN UNDERWRITERS, INC. AND MY FINANCIAL INSTITUTION LISTED BELOW:
ELECTRONICALLY TRANSFER FUNDS TO THE FOLLOWING ACCOUNT:
The regulation promulgated by the Federal Communications Commission (FCC) under the Junk Fax Prevention Act of 2004 requires us to obtain your express written permission to send you faxes that contain “commercial” materials - essentially those that promote our products, programs and services.
So that we can fax your information about our products, programs and services, we ask you give us permission to communicate this type of information to you via fax. Please complete, sign and include this form to us along with the other documents required for appointment consideration with Appalachian Underwriters, Inc.
Please be assured that Appalachian Underwriters values your right to privacy. If you have any questions, please contact us at (888) 376-9633.
I am authorized to and hereby give consent for the organization listed above to receive faxes at the number(s) listed above. I further agree that my express permission to receive faxes will continue and have no date of expiration, unless revoked by me in writing.
This is required to view your commission.
Now that we have different levels of access for our Agency Online portal, you can customize the level of access for the employees at your producing location. All users should have self-registered on our website before access can be updated. Also note that you can change these levels of access at any time. There are three levels of access available to Agency Portal users as described below:
By signing below, I acknowledge that I am authorized to grant the requested access to the user listed on this form and agree to the terms and conditions as outlined on our Agency Agreement with Appalachian Underwriters, Inc.
We appreciate loyalty from our appointed agents and reward them with $100 when they refer a new agency. Tell us who the agent is that referred you below.
Remember, once you are appointed you can also earn $100 for referring new agencies!
*Only the newly appointed agency can turn in this referral form. Only one referral form is allowed per newly appointed agency. Referral forms are only acceptable within 30 days of ‘Active’ status date.
Please answer all questions below.
All questions answered "Yes" to are subjective to review, and are not an immediate disqualification.
Please click Submit below to be redirected to the AUI Acrisure Agency Appointment form.
Please allow up to a minute for the form to submit