Intake Form
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    To start, please input the ID sent to you by Hubspot for this new affiliate.

    Affiliate

    Proposed Agency Name*

    Principal First Name*

    Principal Last Name*

    Principal Agency Partner(s)*

    Domiciled State*


    Office Information

    Office Street Address*

    City*

    State*

    Zip Code*

    Office Phone

    Office Fax

    Work Email*

    Website


    Payment Information

    Onboarding Fee Payment Plan**

    I will contact ASNOA's accounting department after submitting this form to share this affiliate's unique payment plan information.

    Number of Planned Epic Seats Needed*

    Planned Agency Launch Date*

    Number of Complimentary EZLynx/Epic Months*

    Referred By

    Referral Payment Type

    Contract Type

    Important Notes or Concessions:*

    Any Existing Codes or Books?*


      Agency Information

      Agency Name*

      State*

      Type of Staff*

      (Select the option which closest resembles their responsibilities and permissions)


      New Staff Information

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

      First Name*

      Last Name*

      Preferred Name

      (If none, leave blank)

      Date of Birth*

      Home Address*

      (Please include street address, city, state, and zip code)

      Office Address*

      (Please include street address, city, state, and zip code)

      Direct Phone*

      Work Email*




      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?*

      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


      What types of Epic reports will this new staff member need?*

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



      Does this staff member need Applied Epic training?*

      Yes, they need trainingNo


      Will this staff member need his/her own comparative rater credentials (such as EZLynx)?*



      License Information

      Is the staff member licensed?*

      Yes, they are licensedNo, they are not licensed


      Insurance License Number:

      Resident State:

      Please Attach a Copy of Your Domiciled State License:




      Commission Information

      Is this 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 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?




      Carrier Information

      Do you need new carrier credentials for this staff member?*


      Do you want this staff appointed with all personal lines carriers?

      Do you want this staff appointed with all commercial lines carriers?

      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 access to those states, and staff must be personally licensed in those states)

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

      User ID:

      Password:

      PIN (If changed from default 1051):

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

      User ID:

      Password:



        Agency Information

        Agency Name*

        State*

        Type of Staff*

        (Select the option which closest resembles their responsibilities and permissions)


        New Staff Information

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

        First Name*

        Last Name*

        Preferred Name

        (If none, leave blank)

        Date of Birth*

        Home Address*

        (Please include street address, city, state, and zip code)

        Office Address*

        (Please include street address, city, state, and zip code)

        Direct Phone*

        Work Email*




        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?*

        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


        What types of Epic reports will this new staff member need?*

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



        Does this staff member need Applied Epic training?*

        Yes, they need trainingNo


        Will this staff member need his/her own comparative rater credentials (such as EZLynx)?*



        License Information

        Is the staff member licensed?*

        Yes, they are licensedNo, they are not licensed


        Insurance License Number:

        Resident State:

        Please Attach a Copy of Your Domiciled State License:




        Commission Information

        Is this 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 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?




        Carrier Information

        Do you need new carrier credentials for this staff member?*


        Do you want this staff appointed with all personal lines carriers?

        Do you want this staff appointed with all commercial lines carriers?

        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 access to those states, and staff must be personally licensed in those states)

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

        User ID:

        Password:

        PIN (If changed from default 1051):

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

        User ID:

        Password: