Provider Sign Up Request

Provider Sign Up Request
Abbit Master Trust
This form is used to establish a seller/provider profile with the Abbit Master Trust. The result of Abbit accepting this request is that your company will enter into an escrow agreement and you will be allowed to write, modify and make claims on preneed contracts with Abbit.

Additionally, if you are seeking to transfer your current preneed contracts from another provider, you must first have an escrow agreement in place with the Abbit Master Trust to do so.

If you already have an escrow agreement with Abbit and would like to modify your entity name on file, include other locations, exclude certain locations, or umbrella your different locations then please fill out this form and add a final note that details your specific goal. We will always reach out for clarification and confirmation.
Legal Name of Business
This is the legal name of your LLC, Corporation, etc.
DBA "Doing Business As" Name
This is the name that the public associates with your business.
Business Structure
Business Tax ID #
Establishment License #
Establishment License Expiration Date

MonthDayYear
2 digit month, 2 digit day, 4 digit year
Prepaid Seller/Provider License #
The state may not have issued you this yet. Leave blank if not.
Prepaid License Expiration Date

MonthDayYear
2 digit month, 2 digit day, 4 digit year
Main Business Address

Street Address

Street Address Line 2

CityState

Zip Code
General Email
Your email for general team follow up.
Admin Email
Your email for more sensitive admin info.
Website Address
Phone Number
Format: 0000000000.
Additional Notes
Signer's Legal Name
Print your legal name.
Signer's Title
You must have authority to enter into this agreement.
Signature
Should be Empty: