Agency Appointment Main Agency Name (as recorded by DIFS)(Required) DBA Type of Agency(Required) Corporation Partnership Sole Proprietorship LLC Agency System State ID(Required) Business InformationAddress(Required) Street Address City State / Province / Region ZIP / Postal Code Phone(Required)FaxEmail(Required) Website Year Established(Required) Primary ContactName(Required) First Last Postion/Title(Required) Phone(Required)Email(Required) Background InformationHas Agency ever had a license denied, revoked, suspended, cancelled or non-renewed by any state?(Required) Yes No Is Agency delinquent to any insurance company, general agent, manager or broker?(Required) Yes No Has Agency filed bankruptcy or been discharged from bankruptcy within the last five years?(Required) Yes No Has Agency ever been disciplined, fined or censured by a state insurance department or any regulatory body or court?(Required) Yes No Is Agency now the subject of any complaint, investigation or proceeding that could result in a “Yes” to any of the previous questions?(Required) Yes No Has Agency ever been a party to any Errors & Omissions claims in the last five years?(Required) Yes No If you answered Yes to any question, please provide complete details and appropriate documents.Authorization to obtain background information from independent sources. If Retailers Insurance Company (RIC) deems it necessary to obtain additional background information from independent sources, the Agency authorizes all workers’ compensation boards, industrial accident boards, corporations, companies, educational institutions, persons, or law enforcement agencies, to release all written and verbal information to RIC. The Agency and the Principal/Owner noted below release them from any liability and responsibility in any way related to such requests or disclosures. The Agency understands that RIC may obtain information about the Agency’s background and reputation. This authorization, in original or copy form, shall be valid for this and any future reports or updates that may be requested. The Agency hereby verifies the foregoing answers and statements and declares that they were made under the penalties of perjury. The Agency authorizes RIC to release, for the purposes of processing the Agency’s application for appointment, any information obtained to RIC affiliate or to the principal of the Agency executing this form. The Agency understands and agrees that any misrepresentation of fact, whenever discovered, will be the basis for termination for cause of any such appointment. The Agency agrees to immediately notify RIC of any material changes in the above information.By submitting this form, the applicant acknowledges the above information is accurate to the best of their knowledge and grants permission to RIC to execute a background check if deems it necessary.Date(Required) MM slash DD slash YYYY Agency Principal/Owner(Required) First Last
