Partner with Swyfft + New Age

Agency NPN & Contact Information

Agency
Agency NPN
Please provide an Agency NPN unless the Business Entity Type is an Individual/Sole Proprietor or single-member LLC
Agency Primary Email
Agency Primary Phone
Format: (000) 000-0000.
Would you like to use a different mailing address than the one provided in your Form W-9?
Agency Mailing Address

Street Address

Street Address Line 2

CityState

Zip Code

Agency Principal
Agency Principal Name

First NameLast Name
Agency Principal NPN
Agency Principal Email
Agency Principal Phone
Format: (000) 000-0000.
Allow this person to access to all quotes and policies for this agency on Swyfft.com?

Errors & Omissions Policy Information
E&O Policy Expiration Date

YearMonthDay
4 digit year, 2 digit month, 2 digit dayDate
E&O Policy Number
E&O Policy Limit
E&O Policy Carrier
Upload E&O Declaration Page

Cancelof

ACH Credit Authorization

Please provide the accounting contact information for your agency
Payee Name
Taxpayer ID #
Mailing Address

Street Address

Street Address Line 2

CityState

Zip Code
Commissions & Remittance
Email for Receiving Commission Statements
Email for Remittance Advice
If different from contact email above
Accounting Contacts
Primary Contact Name
Primary Contact Title
Primary Contact Phone Number
Format: (000) 000-0000.
Primary Contact Fax Number
Format: (000) 000-0000.
Primary Contact Email
Secondary Contact Name
Secondary Contact Title
Secondary Contact Phone Number
Format: (000) 000-0000.
Secondary Contact Fax Number
Format: (000) 000-0000.
Secondary Contact Email
Payee Signature
The payee described above hereby authorizes Swyfft, LLC to initiate automated clearing house (ACH) credit entries the financial institution set forth below in payment of Commissions issued by Swyfft to Payee. This authorization will remain in full force and effect until Swyfft receives written notification of termination and has a reasonable period of time (not less than 10 business days) to act upon such notice.
Signature
Bank Information
Name
Title
Bank Name
Bank Location

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Transit/Routing Number
Bank Account Number
Depository Account Title
Account Type
Please upload a voided check or bank statement (with Transit/Routing and Bank Account numbers)

Cancelof

For the Agency Owner / Principal

By signing the below, I attest all information presented in this form is accurate and correct to the best of my knowledge.
Name

First NameLast Name
Title
Signature
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit year

You're ready to submit!
What happens next?
- We'll review and reach out with any questions
- If approved, we'll then sign our Producer Agreement
- Lastly, we'll send a welcome email to your agents with account credentials and links to onboarding resources
Should be Empty:

Rows	Yes	No
Has anyone in the agency been refused any policy or application for errors and omissions insurance or been declined, cancelled or renewal refused within the last five years?
Have any errors and omission claims been made against you within the last five years? (If yes, please leave an explanation with full details, nature of claim, date of claim, loss payments and disposition, E&O carrier handling, claim, etc)
Are there any circumstances, including threatened or pending action, which may result in any errors and omissions claim being made against you?
Has anyone in the agency been a part to any criminal proceedings or civil lawsuits (other than minor traffic offenses)?
Has any employee, including agency principals, of the agency received disciplinary action or are under investigation by a state or regulatory agency?
Has any insurance license been suspended or revoked?
Has the agency ever had a contract cancelled by a company for reasons other than lack of volume?
Has the agency and/or any of the principals ever declared or in the process of bankruptcy?

Background Information