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.Format: (000) 000-0000.
Agency Primary Email
example@example.com
Agency Website
*If applicable
Agency Entity Type
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.Format: (000) 000-0000.
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.
Agency Contacts
W-9 and Errors & Omissions (E&O)
Do you have a completed W-9?
Agency FEIN
Please complete and download the current W-9 version below:

CURRENT IRS FORM W-9
Please upload your completed W-9 (March 2024 version) below:

Cancelof
E&O Carrier Name
E&O Expiration Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
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

Other
Financial Institution Name
Financial Institution Address

Street Address

Street Address Line 2

CityState

Zip Code
Account Number
Bank Transit/ABA Number
Signature
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Please upload a copy of a voided check below:

Cancelof
Agency Agreement
I would like to Opt Out of working with the following:
Have you been convicted of any felonies in the last 5 years?
Please provide details on the felony(ies):
Have you or your agency had any disciplinary action from the Department of Insurance?
Please provide details on the DOI action:
Signature
INVO Underwriting Signature
MIAN Signature
WCIE Signature
Name
Title
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Referral Source
Please provide details on Other Referral Source
Please provide details
Does your Agency want access to biBerk?
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