Agency Merger and Acquisition Form
Your Name
*
First Name
Last Name
Your Email
*
example@example.com
Your Phone Number
*
Please enter a valid phone number.
Purchasing Agency Name
*
Purchasing Agency Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Selling Agency Name
*
Selling Agency Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Agency Errors and Omissions Policy
*
Browse Files
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of
Agency License
*
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of
W9 Form
*
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Buy Sell Agreement
*
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Accounting Contact
The accounting contact will receive an ACH document containing information about commissions.
Accounting Contact Name
*
First Name
Last Name
Accounting Contact Email
*
example@example.com
Accounting Contact Phone Number
*
Please enter a valid phone number.
Who will be signing the producer agreement?
Producer Agreement Name
*
First Name
Last Name
Producer Agreement Email
*
example@example.com
Producer Agreement Phone Number
*
Please enter a valid phone number.
Policy Transfer
All policies belonging to the purchased agency will be assigned to a single transfer agent at renewal.
Transfer Agent Name
First Name
Last Name
Transfer Agent Email
example@example.com
Transfer Agent Phone Number
Please enter a valid phone number.
What do you want done with the purchased agency?
*
Make the purchased agency a sublocation of your agency.
Other
If Other, please explain
*
Sublocation Agency Name
*
Sublocation Agency Email
*
example@example.com
Sublocation Agency Phone Number
*
Please enter a valid phone number.
Sublocation Agency FEIN (Federal Employer Identification Number)
*
Sublocation Agency NPN (National Producer Number)
*
Sublocation Agency Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
IVANS Y-Account Number
IVANS User Id
Submit
Policy Number
Should be Empty: