Completion of this form does not automatically authorize you as an AFIG Producer

   
 

AGENCY APPOINTMENT REQUEST

     
  Name of Your Agency
  Address
   
  City
  State
  Zip Code
     
  Contact Name
  Contact Title
  Phone
  FAX
  Email
  Entity Type
  Date Agency Established
  D&B Number
  (if known)
  Tax ID or SSAN
  License Number  (Copy of license required for appointment)
  E&O Insurer
   (Dec page or cert required for appointment)
  Comments / Product Interest
   

BROKER'S AGREEMENT

The undersigned, a duly licensed Agent/Broker in the state you reside, hereinafter referred to as the 'Producer', desiring to submit to Allen Financial Insurance Group, Inc. (AFIG) applications for insurance, agrees to the following:
 

  1. That the Producer is acting as Agent or Broker for the applicant and in the applicant's behalf, not as agent of AFIG and that no binding authority is granted or delegated by this agreement.
  2. That, without exception, if coverage is bound by AFIG, a charge is made in accordance with the policy terms and that there are no flat cancellations, and all fees for the policy term are fully earned on the effective date of coverage.
  3. That the Producer accepts full and entire responsibility to AFIG for the collection and payment of all premium (including minimum earned premiums, but not including premium audits), fees and taxes.
  4. Upon submission of this form the Producer agrees to our "Online Terms and Conditions" whenever using or viewing our websites.

AFIG agrees to pay the Producer commissions according to the current commission structure provided that all premiums, fees, taxes, or unearned commissions are fully paid as herein agreed, the Producer shall retain full ownership and control of all expirations.
 

 

 

 

   


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Contact Information

Phoenix, AZ (602) 992-1570   Toll Free (800) 874-9191
Del Mar, CA (858) 759-9191   FAX (602) 992-8327
Denver, CO  (303) 377-9180      
Portland, OR  (503) 608-4820   P.O. Box 6230  Scottsdale, AZ   85261
     

General Information: ballen@eqgroup.com              Customer Service: mpallante@eqgroup.com
Mortality:
apoling@eqgroup.com                               Entertainment: entertainment@eqgroup.com                   Webmaster:
ballen@eqgroup.com