Founders Agency Application

Agency Application
Any questions or issues with the form? Contact Marketing@wholesure.com
Is your agency an Acrisure Partner?
Is your agency an Evolution Advisors agency?
A master agency agreement between Acrisure and Founders Professional is kept in the custody of Acrisure Regulatory Affairs. As Acrisure Partner agencies engage Founders Professional, their agencies will be added to the master agreement via addendum. Acrisure still requires each partner agency to complete the subsequent pages of this document for Founders Professional. Thank you.
Agency Information
Agency Name
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Federal Tax ID
DBA
Physical Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Is physical address same as biling?
Billing Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Please provide contact information below:

Rows	Name	Phone Number	Email
Agency Principal Contact
Marketing Contact
Accounting Contact

Founders Professional specializes in the placement of Professional Liability, E&O, Management Liability and Cyber/Privacy insurance. Please let us know a little more about your agency focus in these areas.

Rows	Premium Volume	Contact	Phone Number	Email
Architects & Engineers
Lawyer's Professional Liability
Medical Professional Liability
Miscellaneous E&O
Cyber/Privacy
D&O/EPLI

Founders Professional can assist you with your agency's E&O coverage. Who should we contact to provide information?

Rows	Name	Phone Number	Email
Agency E&O Contact

Founders Professional can offer premium finance quotes for your policies. Who should we contact to provide information?

Rows	Name	Phone Number	Email
Premium Financing Contact

This agreement made and entered into this on:

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
E&O and Licenses
Agency's insurance agents E&O declarations page

Cancelof
Agency's Insurance License(s)

Cancelof
W-9/Tax Information

**This information will be used to prepopulate a W-9 on your behalf**
Name (as shown on your income tax return)
Business name/disregarded entity name, if different from prior question
Check appropriate box for federal tax classification of the person whose name is entered above
Mailing Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Mailing Address same as Location Address?
Location Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Please select the LLC Tax Classification:
Any exemptions?
Exempt payee code (if any)
Exemption from FATCA reporting code (if any)
Employer Identification Number
Social Security Number
Signature
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Direct Deposit
Deposit of Direct Bill Commission
Bank Name
Account Name
Routing Number
Account Number
Type:
Deposit of Return Premium
Bank Name
Account Name
Routing Number
Account Number
Type:
Please upload voided check(s) or bank letter for account number verification

Cancelof
Authorization
I hereby authorize Founders Professional, LLC to make credit entries to my (our) account(s) at the depository financial institution named above. The authority will remain in effect until I have given notice of its termination or until Founders Professional LLC, or my financial institution, has given notice that this direct deposit has been terminated. I understand that I must give advance notice of ten (10) business days to allow reasonable time for my instructions to be executed.

In witness whereof, the parties hereto have signed this Agreement effective the day and year first written above.
Signature
Printed Name

First NameLast Name
Printed Name

First NameLast Name
Title
Title
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Please verify your agency's entity type
Should be Empty:

Agency Application

Agency Information

E&O and Licenses

W-9/Tax Information

Direct Deposit

Authorization