temp page – Tim Parkman Insurance

Agency Name (as shown on W9) *

DBA Name

Federal Tax Classification *

Tax Classification Code *CSP

Description

Taxpayer Identification Number *Social Security NumberFederal Employer Identification Number

SSN *

FEIN *

Are your physical and mailing addresses the same? *YesNo

Physical Address *

Apartment, suite, etc

City *Clinton

State *

ZIP / Postal Code *

Mailing Address *

Apartment, suite, etc

City *Clinton

State *

ZIP / Postal Code *

Primary Agency Contact Name *

Title

Phone *

Email Address *

Is this person authorized to sign the Agency Agreement? *YesNo

Authorized Signer for Agency Agreement:After we have received and reviewed all necessary paperwork, we will prepare the required documents for signature. These will be sent via DocuSign to an authorized officer of your company. Please provide the following details for the individual who will be signing the agency agreement and other pertinent documents:

Name of Authorized Signer *

Title

Phone *

Email Address *

Authorized Signer for Agency Agreement

After we have received and reviewed all necessary paperwork, we will prepare the required documents for signature. These will be sent via DocuSign to an authorized officer of your company. Please provide the following details for the individual who will be signing the agency agreement and other pertinent documents:

Agency UsersPlease enter all agency personnel that will need access to our online systems.

Name *

Title

Phone *

Cell Phone

Would you like to receive policy updates via text (SMS)? *YesNo

Email Address *

User Permissions - Additional Info

To learn more about each option listed below, click here.

Producer: Is this user a licensed producer?

Admin: Should this user be given admin access to your agency profile?

View Commissions: Should this user be able to view commission reports?

Enter Payments: Should this user be able to enter payments for policies?

Personal Lines: Allow access to Personal Lines products/marketing info?

Commercial Lines: Allow access to Commercial Lines products/marketing info?

Please upload a copy of the producer license(s) for this user for all states they will need access to. *

Would you like to enable adding Agency Policy Fees for non-Admitted business? *YesNoThe agency fee is collected as part of the downpayment and is remitted with the commissions on the following month's statement. Additionally, the agency fee is billed at the time of renewals.

Would you like to setup Agency Download for Personal Lines policies? *YesNoAgency download refers to the process of automatically transferring policy information, such as client details and policy documents, from our system to your agency management system. For personal lines policies, this ensures that all relevant data is seamlessly integrated into your agency's database, reducing manual entry and streamlining policy management. This process helps maintain accurate and up-to-date records.

Contact Name for Agency Downloads *

Phone *

Email Address *

Agency Management System Used

Would you like to set up an Agency Sweep account? *YesNoAn agent sweep account is a designated bank account used to collect premiums from policyholders. These funds are then periodically "swept" from the account. Setting up an agent sweep account allows for efficient management of premium collections and ensures timely payments to the carriers. It simplifies the reconciliation process and helps maintain accurate financial records.

Renewal RemindersTPI is pleased to offer automated reminders for upcoming policy renewals and notifications for any recentlyexpired policies. To ensure that the right individuals receive these updates, please provide the email addresses of all intendedrecipients in the space below. If no email addresses are specified, we will default to using the primary email address noted above. Ifyou would prefer not to receive these updates, please select the ‘opt-out’ option below.

Email Address

Opt out of all automated reminder emails

Please note:

Since you have not provided an email address and have not opted out, renewal notifications will automatically be sent to: {email-1}.

Please upload your Agency License(s) and E&O Dec Page *

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