INDEPENDENT PARTNER AGREEMENT
CONTRACT FOR SERVICES
Partner Applicant Name
*
First Name
Last Name
Legal Business Name
This should match your 1099 tax document for payment
Business Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Mailing Address (If this is the same, leave blank)
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Partner Type
*
Please Select
Broker
Agent
Inspector
Note: All Broker/Agents are eligible for inspections
Email
*
example@example.com
Phone Number
*
Please enter a valid phone number.
E&O Insurance Declaration Page
*
Proof of coverage
E&O Claim Limit Per Occurance
*
Coverage per incident
E&O Expiration Date
*
Name Of The Insured Person
*
This is the provider who is insured
Has license been denied, revoked or suspended?
Please Select
Yes
No
Has your license been denied, revoked or suspended in the past?
Are You Interested In Desktop Valuation Assignments?
*
Yes
No
Unsure
FILLABLE ONLINE W9 FORM
(Or upload 2024 Version of completed W9)
License (If Applicable)
*
Browse Files
Drag and drop files here
Choose a file
Email additional licenses to contactus@valligent
Cancel
of
Signed W9 (2024 Version Required) Or Use Link
Browse Files
Drag and drop files here
Choose a file
Upload or complete online form below (Only one is required)
Cancel
of
State Licenses or certifications
*
Coverage Area(s)
*
Signature
*
Todays Date
*
Please verify that you are human
*
Continue
Continue
Should be Empty: