Agency Application
Agency Information
Agency Name
*
Include DBA
Agency Address
*
Street Address
Street Address Line 2
City
Please Select
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
State
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 Name
Last 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.
*
Yes
No
Agency Contacts
*
W-9 and Errors & Omissions (E&O)
Do you have a completed W-9 (Oct. 2018 version)?
*
Yes
No
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:
*
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E&O Carrier Name
*
E&O Expiration Date
*
-
Month
-
Day
Year
Date
Please upload a copy of your E&O Declaration Page or COI below:
*
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of
Licenses
Please upload all Agency Licenses:
*
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Please upload all Individual Licenses:
*
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Electronic Funds Transfer (EFT)
Account Holder
*
Account Type
*
Checking
Savings
Money Market
Other
Financial Institution Name
*
Financial Institution Address
*
Street Address
Street Address Line 2
City
Please Select
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
State
Zip Code
Account Number
*
Bank Transit/ABA Number
*
Signature
*
Date
*
-
Month
-
Day
Year
Date
Please upload a copy of a voided check below:
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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?
*
Yes
No
Please provide details on the felony(ies):
*
Have you or your agency had any disciplinary action from the Department of Insurance?
*
Yes
No
Please provide details on the DOI action:
*
Signature
*
INVO Underwriting Signature
*
MIAN Signature
*
WCIE Signature
*
Name
*
Title
*
Date
*
/
Month
/
Day
Year
Date
Referral Source
*
Please Select
Jeffrey Cox
Tina Mullins
Krystal Callaham
Candy Orr
Christy Land
Dianna Sexton
George Kaspars
Brandon Leonard
Josh Willis
Traci Farley
Caryn Dipaola
Web Search
LinkedIn
Facebook
QuoteMyWC.com
INVO PEO Employee
Other
Please provide details on Other Referral Source
*
Please provide details
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