Part 1 - Tax Identification:
Click here for W-9 Instructions
Part 2 - Exemption: If exempt from Form 1099 reporting, check
your qualifying exemption reason below:
Part 3 - Signature: I am a U.S. person (including a U.S.
Licensing Data Transmittal Authorization
Information and authorization requested in this section applies to all licensed producers who sell flood insurance and is used to ensure producers have appropriate licensing.
Click here for Request Transmittal Procedures
General Agent or Managing General Agent Section
Managing General Agent Section
General Agent Section
Agency - Complete all sections & include a copy of the Agency License
(*Note: You will be required to provide a copy of your P&C license for each state selected. Licensed NY producers may also be required to provide a broker license.)
Producing Agent Section - Complete all sections
Note: Each Producing Agent must complete a new producer form and provide a copy of their license(s)
Please have each producer complete and sign a "New Producer" form and submit all completed forms with your enrollment package to the Marketing Rep.
Completion of a Flood Training Course is required before an agent can sell Flood policies. Please complete the section below with the pertinent data of the course taken satisfying this requirement.
Non-Licensed/Non Producing System Users
Use this section to request view only CSR level access for non-licensed/non-producing users.
Before submitting this package, please upload copies of applicable agency and/or producer licenses. You may upload multiple licenses at the same time.
State Requirements:Licensed NY producers may also be required to upload their broker license.
Note: Missing licenses will delay processing.
Generate Package for Signature(s)
Please note if you continue with this action, you will lose all data that has already been entered.
Would you like to continue?
Please provide or correct the information in the fields highlighted in red. You can refer to the error message(s) associated with each field.
Once finished with these corrections, please try clicking the Generate Package for Signature(s) button again to start signing. Thank you.