Intake FormTesting New Affiliate Intake Form Staff Intake Form Testing WP Mailer New Affiliate Intake Form 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)* ---Kevin RigsbyBrian BradleyMary Beth StiltnerScott LovelandMichael PetrocelliDavid WilsonSteve Gebhardt & Ralph KayeRoger Collins Domiciled State* Office Information Office Street Address* City* State* Zip Code* Office Phone Office Fax Work Email* Website Payment Information Onboarding Fee Payment Plan** ---$5,000 One Time Payment$2,500 + 11 Payments of $250$1,000 + 48 Payments of $100$1,000 + 30 Payments of $150$10,000 One Time Payment$5,000 + 30 Payments of $200$3,000 One Time Payment$1,500 immediate + $1,500 at signing$1,500 immediate + $150 for 10 months$1,000 immediate + $2,000 at signing$500 One Time PaymentOther- Notify Accounting 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 ---One-Time PaymentOngoing Contract Type ---DeluxeDeluxe with Services Important Notes or Concessions:* Any Existing Codes or Books?* Δ Staff Intake Form Agency Information Agency Name* State* Type of Staff* (Select the option which closest resembles their responsibilities and permissions) ---CSRProducerManager New Staff Information Is this a new staff member or are you updatinginformation for an existing employee?* ---New HireUpdating Existing Staff Member 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 . Book of BusinessNew BusinessDashboard & SalesProduction/ProducerActivitieseDocDownloads & SuspenseClaimsCancellationExceptionsExpirationDeduction StatementClient ListBirthday List 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)?* YesNo 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? ---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 personal lines carriers? YesNo Do you want this staff appointed with all commercial lines 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 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: Δ Testing WP Mailer Agency Information Agency Name* State* Type of Staff* (Select the option which closest resembles their responsibilities and permissions) ---CSRProducerManager New Staff Information Is this a new staff member or are you updatinginformation for an existing employee?* ---New HireUpdating Existing Staff Member 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 . Book of BusinessNew BusinessDashboard & SalesProduction/ProducerActivitieseDocDownloads & SuspenseClaimsCancellationExceptionsExpirationDeduction StatementClient ListBirthday List 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)?* YesNo 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? ---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 personal lines carriers? YesNo Do you want this staff appointed with all commercial lines 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 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: Δ