INVO Underwriting Agency Application

Agency Application
Agency Information
Agency Name*
Include DBA
Agency Address*

Street Address

Street Address Line 2

CityState

Zip Code
Agency Phone*
Please enter a valid phone number.
Agency Primary Email*
example@example.com
Agency Website*
*If applicable
Agency Entity Type:*
Ex: Corporation, LLC, Sole Proprietorship, etc.
Contacts
Main Contact Name*

First NameLast Name
Main Contact Email*
example@example.com
Main Contact Phone*
Please enter a valid phone number.
Main Contact Role*
Do you have other agency contacts you would like to provide? This will give them access to INVO's Agent Portal for online quoting/binding.*

YesNo
Agency Contacts*
W-9 and Errors & Omissions (E&O)
Do you have a completed W-9 (Oct. 2018 version)?*

YesNo
Agency FEIN*
Please complete and download the W-9 Oct. 2018 version below:

Oct. 2018 W-9
Please upload your completed W-9 (Oct. 2018 version) below:*

Cancelof
E&O Carrier Name*
E&O Expiration Date*

MonthDayYear
Date
Please upload a copy of your E&O Declaration Page or COI below:*

Cancelof
Licenses
Please upload all Agency Licenses:*

Cancelof
Please upload all Individual Licenses:*

Cancelof
Electronic Funds Transfer (EFT)
Account Holder*
Account Type*

CheckingSavingsMoney MarketOther
Financial Institution Name*
Financial Institution Address*

Street Address

Street Address Line 2

CityState

Zip Code
Account Number*
Bank Transit/ABA Number*
Signature*

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Date*

MonthDayYear
Date
Please upload a copy of a voided check below:

Cancelof
Agency Agreement
I would like to Opt Out of working with the following:

INVO Underwriting (All Commercial Lines)MIAN (Personal Lines)WCIE (PEO & WC Solutions)
Have you been convicted of any felonies in the last 5 years?*

YesNo
Please provide details on the felony(ies):*
Have you or your agency had any disciplinary action from the Department of Insurance?*

YesNo
Please provide details on the DOI action:*
Signature*

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INVO Underwriting Signature*

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MIAN Signature*

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WCIE Signature*

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Name*
Title*
Date*

MonthDayYear
Date
Referral Source*
Please provide details on Other Referral Source*
Please provide details
Does your Agency want access to biBerk?*

YesNo
By completing this application, your agency will be opted-in to email communication on our product offerings, new carriers, agent incentives, and more.
Opt Out on PDF
Should be Empty:

Agency Application

Agency Information

Contacts

W-9 and Errors & Omissions (E&O)

Licenses

Electronic Funds Transfer (EFT)

Agency Agreement