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* —Please choose an option—AKALARAZCACOCTDEFLGAHIIAIDILINKSKYLAMAMDMEMIMNMOMSMTNCNDNENHNJNMNVNYOHOKORPARISCSDTNTXUTVAVTWAWIWVWYDC 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) —Please choose an option—CSRProducerManagerPocket Agent First Name* Last Name* Preferred Name Work Email* Must be a working, unique email address associated with your agency. If you do not have this yet, carrier appointments and rater accounts will be delayed until we have received this. Is this a new staff member or are you updating information for an existing employee?* —Please choose an option—New HireUpdating Existing Staff Member 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. Applied Epic Information Does This Staff Member Need Applied Epic Access?* YesNo Please indicate which type of Applied Epic access this staff member will need? (Select only one) AgencyBranchProfit Center "Agency" = 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 What types of Epic reports will this new staff member need? (Select all that apply.) You can find descriptions of the Epic reports by clicking here . Book of BusinessNew BusinessDashboard & SalesProduction/ProducerActivitieseDocDownloads & SuspenseClaimsCancellationExceptionsExpirationDeduction StatementClient ListBirthday List Does this staff member need Applied Epic training?* Yes, they need trainingNo License Information Is the staff member licensed?* YesNo In order for us to begin any appointment setup, this person MUST have a work email associated with your agency. Insurance License Number*: License State*: —Please choose an option—AKALARAZCACOCTDEFLGAHIIAIDILINKSKYLAMAMDMEMIMNMOMSMTNCNDNENHNJNMNVNYOHOKORPARISCSDTNTXUTVAVTWAWIWVWYDC Does this license have an expiration date? —Please choose an option—YesNo License Expiration Date: Please Attach a Copy of Domiciled State Actual License: We cannot begin any other processes without a copy of this license. Commission Information Is the staff member paid commission?* YesNo Please remember, splits are based on your total commission at 85%, instead of out of 100%. For example, if you want to split your commission 50/50 with a producer, you would type "42.5/42.5." Please enter the split an the order reflecting "producer amount/principal amount". Please direct your questions to training@asnoa.com . Staff member new business split percentage Staff member renewal split percentage Are there special splits or considerations for any other lines? If you are updating commissions for an existing staff member, are the commissions laid out above meant to replace the current commission structure or serve as an add on structure? —Please choose an option—Replace current commission structureAdd on to existing commission structure Carrier Information* Do you need new carrier credentials for this staff member?* YesNo Do you want this staff appointed with all PL carriers? YesNo Do you want this staff appointed with all CL carriers? YesNo Are there any carrier exceptions that can be made (carriers that are rarely used or wouldn't benefit the staff member)? What states need to be authorized? *Agency must have existing access to those states. **The staff member must be personally licensed in all states requested. In order to process ASI's appointment, we need your agency credentials: User ID: Password: In order to process Clearcover's appointment, we need your agency credentials: User ID: Password: In order to process Openly's appointment, we need your agency credentials: User ID: Password: Comparative Rater Information Will this staff member need his/her own comparative rater credentials (such as EZLynx)?* In order to receive any comparative rater info or setup, this person MUST have a work email associated with your agency. YesNo Submit button will appear when responses are entered for all required questions above. Δ
