U.s. Insurance Brokers Form

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U.S. Insurance Brokers, Inc.
“WRITE YOUR OWN” FLOOD INSURANCE PROGRAM
AGENCY ENROLLMENTMENT ( 20% NEW, 20% RENEWAL, 20% ROLLOVER)
The information requested below is required in order for you to sell flood insurance through U.S. Insurance Brokers. The
Harford Fire Insurance Company, and National Flood Services (NFS). Please complete and return this form along
with the W-9 Tax ID Form to NFS at the address listed below. Within two weeks, you will receive from them all the
supplies and information necessary for you to write flood insurance. Please keep a copy of this document for your files.
Please Print or Type
AGENCY NAME: ________________________________________________
___________________________________________________________
Business Address
___________________________________________________________
Mailing Address
_________________________________________________________________
_________________________________________________________________
Business Phone No.
(
)
______________________________________________________
Business Fax No.
(
)
______________________________________________________
E-Mail Address
_________________________________________________________________
IRS Tax ID No.
_________________________________________________________________
Errors & Omissions Policy _____________________________________________________________
(Dates, Limits and Company)
Agency Contact Person _______________________________________________________________
Commission Checks Payable to: ______________________________________________________
Do you currently write Flood Insurance?
___ Yes
___ No
Number of Policies __________________
Premium Volume
__________________
Will you transfer that business to U.S. Insurance Brokers
___ Yes
___ No
Are you interested in flood training?
___ Yes
___ No
PLEASE ATTACH A COPY OF YOUR CURRENT PROPERTY AND CASUALTY LICENSE
Mail to:
Customer Service:
1-800-637-3846
National Flood Services
P.O. Box 2057
Agency Services:
1-888-888-2169
Kalispell, MT 59903-2057
Agency Services Fax: 1-406-755-4403
IF YOU HAVE ANY QUESTIONS, PLEASE CALL: National Flood Services at 1-888-888-2169
.
U. S. Insurance Brokers, Inc.
Park Place, 13394 SW 128 Street, Miami, FL 33186
Phone: (305) 234-4700 ♦ Fax: (305) 234-4701
C
opyright, U.S. Insurance Brokers, Inc., 2007

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