Staff Intake Form

Fill out this form for new hires or to update existing staff.

    Affiliate Information

    Items marked with a asterisk are required fields.

    Name of Agency*

    State*

    Email of Person Completing this Form*

    A submission receipt will be sent to this address.



    Staff Information

    Items marked with a asterisk are required fields.

    Type of Staff*
    (Select one option from below that most applies to the staff member's job title)

    First Name*

    Last Name*

    Preferred Name

    Work Email*

    Is this a new staff member or are you updating information for an existing employee?*

    Reason(s) for Update:

    Name ChangeEmail ChangeAddress ChangePhone ChangeEpic Access or Training ChangeCommission ChangeLicensing ChangeCarrier Credential ChangeRater Access Change


    Home/Personal Address*

    Street* (home/personal)

    City* (home/personal)

    State* (home/personal)

    Zip Code* (home/personal)

    Office Address (Include: Street Address, City, State, Zip Code)

    Direct Phone*

    Date of Birth*

    Hire Date*

    Start Date*

    Please double-check the dates entered to confirm they are entered in the mm/dd/yyyy format.





    YesNo

    AgencyBranchProfit Center

    "Access" = Access to full company information (all branch codes associated with the agency)

    "Branch" = Access to only that staff member's specific branch code information

    "Profit Center" = Access to only the specific commission split information given to that staff member



    You can find descriptions of the Epic reports by clicking here .





    Yes, they need trainingNo



    YesNo









    YesNo
























    In order to process ASI's appointment, we need your agency credentials:



    In order to process Clearcover's appointment, we need your agency credentials:



    In order to process Openly's appointment, we need your agency credentials:


    Comparative Rater Information


    Submit button will appear when responses are entered for all required questions above.