STEPS Essentials Authorization Form

STEPS Essentials Authorization Form

Simply provide the information requested below.
Agency Information:

Provide the requested information about your agency.
Contact Name*

First NameLast Name
Agency Name*
Email*
Agency Code*
Agency Phone*

Area CodePhone Number
Agency's Website URL
I have read and understand the following statement:

By clicking the “submit” button you are activating your agency’s participation in this program and authorize Auto-Owners Insurance to bill your monthly agency bill statement $125/month to cover the out-of-pocket portion for the program. I understand this will be a recurring charge until such time as I choose to cancel from the program. I also understand that my co-op budget will be reduced $1,500/annually (pro-rated in the first year). In the event that there is a shortage of co-op budget dollars, the remaining amount will be charged to my monthly agency bill statement in separate monthly charges. The maximum amount you could be charged for this program would be $3,000 annually. I understand the billing will start immediately for this program.
Authorization*

Yes, I have read and understand the above statement.
Activation*

By submitting this form, you are activating your agency’s participation in this program.
Electronic Signature*
Verification code: Enter the message as it's shown*
Should be Empty: