RELIANCE RISK SOLUTIONS AGENCY APPOINTMENT

AGENCY NAME*
ARE BILLING AND LEGAL ADDRESSES THE SAME AS THE PHYSICAL ADDRESS?*

YESNO
ADDRESS FOR AGENCY AGREEMENT (HIDDEN)

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
AGENCY NAME FOR AGENCY AGREEMENT (HIDDEN)
PHYSICAL ADDRESS*

Street Address

Street Address Line 2

CityState

Zip CodeCountry
BILLING ADDRESS*

Street Address

Street Address Line 2

CityState

Zip CodeCountry
LEGAL NOTICES SHOULD BE SENT TO:*

Street Address

Street Address Line 2

CityState

Zip CodeCountry
SEND COMMISSIONS / INVOICES TO:*

BILLING ADDRESSPHYSICAL ADDRESS
WEBSITE ADDRESS*
PRIMARY EMAIL ADDRESS*
example@example.com
AGENCY PHONE NUMBER*
AGENCY FAX
PRIMARY AGENCY CONTACT NAME*
PRIMARY AGENCY CONTACT EMAIL*
example@example.com
AGENCY OWNERSHIP TYPE*

SOLE PROPRIETORSHIPPARTNERSHIPLIMITED LIABILITY CORPORATIONC CORPORATIONS CORPORATION
BUSINESS TAX ID*
PLEASE UPLOAD A COMPLETED MARCH 2024 W9 FORM*

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WHAT YEAR DID YOUR AGENCY START?*

0/4
E&O CARRIER NAME*
E&O POLICY NUMBER*
E&O POLICY EXPIRATION DATE*

MonthDayYear
Date
PLEASE UPLOAD EVIDENCE OF YOUR AGENCY'S E&O INSURANCE*

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AGENCY AND AGENT LICENSE(S)

NOTE: Please include a copy of each licence listed
IN WHICH STATE IS YOUR AGENCY PRIMARILY LICENSED?*
WHAT IS THE AGENCY'S LICENSE NUMBER IN THAT STATE?*
PLEASE UPLOAD A COPY OF THE AGENCY'S STATE LICENSE

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PLEASE PROVIDE AN AGENT'S NAME THAT HOLDS A STATE LICENSE*
IN WHICH STATE IS THIS AGENT LICENSED?*
WHAT IS THE AGENT'S STATE LICENSE NUMBER?*
PLEASE PROVIDE A COPY OF THE AGENT'S STATE LICENSE

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IN WHAT STATES IS YOUR AGENCY LICENSED TO CONDUCT BUSINESS AND YOU HAVE NOT PROVIDED THE LICENSE INFORMATION?*
IS YOUR AGENCY PART OF A FRANCHISE?*
IF YES, PLEASE LIST FRANCHISE
HAS YOUR AGENCY OR AGENCY PRINCIPAL FACED DOI ACTION PREVIOUSLY?*

YESNO
HAS YOUR AGENCY OR ANY AGENT HAD AN E&O CLAIM IN THE LAST 5 YEARS?*

YESNO
HAS YOUR AGENCY OR ANY AGENT FILED BANKRUPTCY IN THE LAST 5 YEARS?*

YESNO
HAS YOUR AGENCY OR ANY AGENT EVER BEEN CONVICTED OF A FELONY?*

YESNO
IF ANSWERING YES TO ANY OF THE QUESTIONS ABOVE PLEASE EXPLAIN BELOW:

Add Additional Agency Contacts (optional)

The users listed below will be provided login credentials. You can do this at a later date.
NAME*

ACH AUTHORIZATION FORM
I/We authorize Reliance Risk Solutions, LLC and my Financial Institution listed below to electronically transfer funds to the following account:*

CHECKINGSAVINGS
ACCOUNT NAME*
FINANCIAL INSTITUTION NAME*

Street Address

CityState / Province

Postal / Zip Code
PHONE NUMBER*
ACCOUNT NUMBER*
BANK TRANSIT/ABA NUMBER*
DATE

DayMonthYear
Date
SIGNATURE*

Clear
PLEASE UPLOAD A VOIDED CHECK FOR ROUTING AND ACCOUNT NUMBER VERIFICATION*

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The regulation promulgated by the Federal Communications Commission (FCC) under the Junk Fax Prevention Act of 2004 requires us to obtain your express written permission to send you faxes that contain “commercial” materials essentially those that promote our products, programs and services.

So that we can fax your information about our products, programs and services, we ask you give us permission to communicate this type of information to you via fax. Please complete, sign and include this form to us along with the other documents required for appointment consideration with Reliance Risk Solutions, LLC

Please be assured that Reliance Risk Solutions, LLC values your right to privacy. If you have any questions, please contact us at 865-481-2655.
Organization Name for Which Consent Is Being Provided (Agency Name)
Fax Number(s) for Which Consent Is Being Provided
I am authorized to and hereby give consent for the organization listed above to receive faxes at the number(s) listed above. I further agree that my express permission to receive faxes will continue and have no date of expiration, unless revoked by me in writing.
Signature

Clear
Printed Name
Date

DayMonthYear
Date
Should be Empty:

ADDITIONAL LOCATION INFORMATION (EXPAND IF NEEDED)