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*

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



    Staff Information

    Items marked with a asterisk are required fields.

    First Name*

    Last Name*

    Preferred Name

    Home Address* (Include: Street Address, City, State, Zip Code)

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

    Direct Phone*

    Work Email*

    Date of Birth*






    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 .




    YesNo




    YesNo










    YesNo





















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




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



    Comparative Rater Information