Founders Professional Agency Application

Founders Professional Agency Application
Is your agency an Acrisure Partner?*

YesNo
Is your agency an Evolution Advisors agency?*

YesNo
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.
Federal Tax ID*
DBA*
Physical Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Is physical address same as biling?*

YesNo
Billing Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Please provide contact information below:*

	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.*

	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?*

	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?*

	Name	Phone Number	Email
Premium Financing Contact

This agreement made and entered into this on:*

MonthDayYear
Date
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*

Individual/sole proprietor or single-member LLCC CorporationS CorporationPartnershipTrust/estateLimited liability company
Mailing Address*

Street Address

Street Address Line 2

CityState / Province

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

YesNo
Location Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Please select the LLC Tax Classification:*
Any exemptions?*

YesNo
Exempt payee code (if any)
Exemption from FATCA reporting code (if any)
Employer Identification Number*
Social Security Number*
Signature*

Clear
Date*

MonthDayYear
Date
Direct Deposit
Deposit of Direct Bill Commission
Bank Name*
Account Name*
Routing Number*
Account Number*
Type:*

CheckingSavings
Deposit of Return Premium
Bank Name*
Account Name*
Routing Number*
Account Number*
Type:*

CheckingSavings
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.
Printed Name*

First NameLast Name
Title*
Signature*

Clear
Date*

MonthDayYear
Date
Please verify your agency's entity type
Should be Empty:

Founders Professional Agency Application

Agency Information

E&O and Licenses

W-9/Tax Information

Direct Deposit

Authorization