Get Appointed You will need the following documents: Current broker’s license Legible copy of your broker’s bond (if applicable) Current E & O Policy declaration page Completed W-9 Form Need more info? Call (541) 500-2177 to speak to a representative about getting appointed. Get Appointed "*" indicates required fields Legal Agency Name* DBA Mailing Address* Street Address City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Phone NumberAgency is a* Partnership Sole Proprietorship Corporation S-Corporation Federal ID or Sec. No* How did you hear about us?*Contacted by representativeEmailInsurance Journal MagazineInternet SearchMyNewMarketsInstagramFacebookLinkedInReferralTradeshowOtherName of representative Name of person that referred you Name of Tradeshow Other Name of Person having ownership in agency* Email Address All Employees (INCLUDING OWNER)*Employee NameTitleemail addressAdmin Rights Y/N Add RemoveHave you or anyone in your agency been sued concerning insurance related activities?* Yes No Please explainHave you, your employees, or your agency been disciplined by any State Agency or Department of Insurance?* Yes No Please explainHas any Error & Omission claims been made in the most recent five years against your agency, officers, partners or owners?* Yes No Please explainPlease list companies and MGAs you place business with in order of premium volume:*Carrier/MGALoss Ratio Add Remove Please upload appointment requirements: 1.) Legible copy of your current broker’s license 2.) Legible copy of your broker’s bond (if applicable) 3.) Copy of your current E & O Policy declaration page 4.) Completed W-9 Form* Drop files here or Select files Max. file size: 512 MB. Consent* I agree to the producer agreement.Producer shall be liable to Company for the full amount of premium, fees and applicable taxes, less commission, including additional and/or adjustable premiums developed under Audits or applicable Rating Plans, on every insurance contract placed by Producer through Company. Producer agrees that payment of any minimum earned premium required by the issuing carrier will be the responsibility of the Producer. Any credit extended to the Insured shall be the sole risk and responsibility of the Producer. 2) Producer shall remit the full amount of premium, fees and applicable taxes, less commission, to Company not later than the twentieth day (20th) day after the effective date of such coverage, contract, audit, rating plan or other adjustment unless mutually agreed upon otherwise in advance and in writing. 3) No insurance contract or policy may be returned to Company by Producer for flat cancellation unless it is returned and received prior to the inception of effective date of the contract and such credit has been credited Company by the carrier. Earned premium shall be computed and charged on every contract cancelled after the inception of effective date, in accordance with the cancellation provisions of such contract. Any taxes applicable to any contract of insurance placed with a carrier, which are not recoverable, are fully earned from the inception date of the NNB 08/2020 2 insurance, and, in case a portion of the premium shall be returned by reason of cancellation either on behalf of the insured or the carrier, or by reason of reduction of premium, no amount shall be returnable in respect of such taxes until and unless such taxes have been, in fact, recovered by Company, and, the amount to be returned shall in no event exceed the amount so recovered. 4) If, after the expiration of sixty (60) days from the effective date of coverage on any policy, Company has not received the full amount due it, Company may, at its sole option, collect directly from the Insured the premium due. In the event Company collects the premium or any part thereof directly from the Insured, Producer shall not be entitled to any commission on the premium so collected. Attempts by Company to collect from the Insured shall not relieve the Producer of any liability to Company except to the extent of amounts actually collected by Company from the Insured, less the expense of such collection. 5) In consideration of commission allowed Producer on all premiums and additional premiums, Producer agrees to refund Company the commission on all return premiums at the same rate such commissions were originally retained. 6) Notwithstanding anything to the contrary herein set forth, in the situation where premiums for coverage which has been bound cannot be fully determined in advance and where an adjustment or determination after a specific time period, by audit or otherwise, shall have been made, then the amount of any additional premium due shall be paid by Producer to Company by the due date on the invoice issued for said additional premium. If premiums resulting from such adjustments or audits are, after diligent collection effort, determined by Producer to be uncollectible, Producer shall notify Company immediately. Company and issuing carrier reserve the right to pursue direct collection from the Insured in this case. If Company is allowed by contract to receive credit from the issuing carrier and concurs that diligent effort has made to collect by Producer, the Producer’s account will be credited accordingly but only after Company’s account has been credited by the issuing carrier. Producer shall not be entitled to commission on premium subsequently collected. NNB 08/2020 3 7) Producer acknowledges that it is not the agent of Company and has no authority to bind Company or any of Company’s principals or carriers. Producer warrants it is the Agent of Insured and acknowledges Company bears no agency or fiduciary responsibility to the insured. The issuance of Certificates of Insurance is the responsibility of Producer. Producer assumes complete responsibility for the accuracy of said Certificates. Producer will indemnify Company and hold it harmless from any liability arising out of the issuance of Certificates that do not accurately reflect the coverage bound and in-force as evidenced by the binder or policy. 8) Company will use its best efforts to give Producer reasonable advance notice of the expiration of all policies but failure of Company to provide such notice will not render Company liable. 9) The Producer’s records and use and control of expirations shall remain the property of the Producer provided the Producer has accounted for and remitted to Company all premiums and return commissions for which it is or may be liable. 10) It is specifically understood and agreed that notwithstanding anything to the contrary herein set forth, this Agreement shall not be interpreted or construed so as to prevent either Producer or Company from executing other similar agreements or to compel Company to accept or place all or any of the business offered to it by Producer. 11) Producer shall indemnify and hold Company harmless against any claim, liabilities or costs (including attorney’s fees and expenses) which Company may become obligated to pay as a result of loss to insureds caused directly or indirectly by an error or omission of the Producer. Company shall indemnify and hold Producer harmless against any claim, liabilities or costs (including attorney’s fees and expenses) which Producer may become obligated to pay as a result of loss to insureds caused directly or indirectly by an error or omission of Company in the processing of any business placed and/or attempted to be placed by Company for Producer. 12) Producer agrees to obtain and maintain, at all times during the term of the Agreement, errors and omissions coverage for its activities as an insurance producer for itself and its agents, NNB 08/2020 4 solicitors, servants and employees in an amount not less than $2,000,000 per occurrence and $2,000,000 in the aggregate with an insurance carrier rated A- V or better by AM Best. If said coverage is secured on a claims-made basis, the retroactive date shall not be later than the date of this Agreement. A copy of the errors and omissions policy, declarations page or other acceptable evidence of coverage shall be submitted to Company annually. Producer shall not discontinue such coverage without providing Company thirty (30) days prior written notice. Any failure to provide such notice or maintain such insurance coverage shall be deemed to be a material breach of this Agreement entitling Company to indemnification for any damages caused thereby. 13) Producer warrants that it is properly licensed to sell insurance in its state of domicile and all other states in which Producer sells insurance. Producer agrees to act in compliance with all laws and regulations regarding the placement of insurance with admitted and/or non-admitted insurance carriers in each such state. Producer agrees to promptly supply copies of any of its insurance licenses when requested by Company and will notify Company of any suspension, revocation or termination of any license. 14)No Producer has authority to assign or adjust any losses on behalf of Company or its carriers. All claims are to be reported immediately to Company by e-mail or fax. Only Company or its carriers may make adjuster assignments for the handling of losses and claims. 15) The furnishing of promotional materials, including but not limited to kits, applications, rate schedules, specimen policies, brochures, advertising or any other material, by Company to Producer does not create or imply an agency relationship or binding authority between Company and Producer. 16) Producer stipulates no business will be co-brokered without the prior written consent of Company. Producer warrants that Producer is the originating retail agent for all insureds, clients or prospects submitted to Company unless Company is notified in advance and specifically agrees. NNB 08/2020 5 17) This Agreement shall apply to all insurance contracts already placed and in force at the date hereof and all future insurance contracts which may be placed by Company on behalf of Producer. 18) This Agreement may be cancelled at any time with ten (10) days written notice by either party to the other, but said cancellation shall not alter in any way the continued application of the Agreement to insurance contracts effected prior to the date of such cancellation. 19) This Agreement constitutes the full and complete contract between Company and Producer. Neither party has relied upon any oral representation not included herein. Any amendment to this Agreement shall be made only with the written consent of both parties and attached hereon through addendum. 20)Assignment by Producer of rights and obligations under this Agreement shall not be valid until Company has given its written authorization to such assignment. 21)Any portions of this Agreement that are not in conformity with State or Local laws are hereby amended to conform to those laws. However, any such amendment to achieve conformity does not abrogate the remainder of the Agreement.Name: Principal Name* By adding my name, and submitting this application I am agreeing that that the statements on this application or any material submitted herewith are true and accurate representation of the applicant and they shall be deemed material to the acceptance of risk(s) from the brokerage by Northeast National Brokerage LLC.Signature Date MM slash DD slash YYYY Signature Reset signature Signature locked. 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