Agency Name:       

 

(use separate sheet for each location)

 

Principal(s) Name(s):      

 

Address:      

Phone Number:      

Fax Number:      

Website (URL Address):      

E-Mail Address:      

 

     COMMISSION – ACH INFORMATION

Name as appears on Bank Account:      

Name of Designated Bank:      

Designated Bank Account Number:      

Bank Transit Number:      

Is there a void check copy attached to use for reference?   

Any questions please call:      

 

     EMPLOYEE LISTING

Employee Name

Job Title

Duties

Phone Ext. &/Or E-Mail Address

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

 

     LIST OF COMPANIES CURRENTLY USING

     

     

     

     

     

     

     

     

 

W-9 Form, completed and executed by agent attached?

 

 

 

     TECHNOLOGY QUESTIONNAIRE

 

Do you have a main frame or outsource?      

List and Description of Computer Hardware:      

List Computer Software currently using:      

Is your office on the internet now?      

Are you on line with other companies?      

If yes, Who, what, how?      

Would you use our Agent Web program?      

Do you have a favorite password?      

Would you be interested in the URB rating program that includes Fulmont Mutual Insurance Company macros?      

(minimum and recommended requirements are listed below)

 

 

Minimum Requirements to run URB Rating and Fulmont Macros:

 

            WINDOWS 95 or higher;

            MICROSOFT EXCEL Version 6.0 and up;

            75 MEGAHERTZ (will run slowly);

            32 RAM Memory;

            8 MEGABYTES available on hard drive;

            CD ROM Drive

 

Recommended Requirements:

 

WINDOWS 97;

            EXCEL 97 System Release – SR-2 – Microsoft Excel “Help”;

            300 MEGAHERTZ;

            64 RAM Memory;

            10 MEGABYTES available on hard drive;

            CD ROM Drive (to install URB Programs);

            3 ½ DISKETTE DRIVE (to install Fulmont Programs);

            E-MAIL (to install Fulmont programs and E-Mail the rated policies)