1. Full Legal Name
4. Home Address
5. Cell Phone Number
6. Individual Producer Email
7. Business Legal Entity Name
8. Business Entity EIN#
9. Year Business Entity was founded
10. Business Entity Location Address
11. Business Entity Phone Number
12. Business Entity Email
13. Business Entity Fax Number
14. Contract Type
15. License Type
16. Resident State Individual Producer License Number
17. Individual NPN#
18. Resident State Business/Agency License Number
19. Business/Agency NPN#
20. If you do not currently have E&O insurance, would you like assistance obtaining a policy?
21. Individual Producer Direct Deposit Information (ABA Routing)
22. Individual Producer Direct Deposit Information (Account #)
23. I attest that I am the owner of this bank account and that I authorize Valor to directly deposit commissions into this account.
24. Here is a link to a blank W9 if needed: Form W-9 (Rev. October 2018) (irs.gov)
25. Business Entity Direct Deposit Information (ABA Routing #)
26. Business Entity Direct Deposit Information (Account #)
27. I attest that I am the owner of this bank account and that I authorize Valor to directly deposit commissions into this account.
28. By typing my name in the signature box below, I affirm and certify that all of the information and answers to questions herein are complete, true, and correct to the best of my knowledge and belief and that this information may be utilized to set up my contractual relationship with Valor.
29. Upload E&O, all applicable licenses and W9 here
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