Insurance
General
Agency, Inc.
Dear Producer:
Attached you will find the required forms to be appointed with RIC Insurance General Agency, Inc.
In order to be appointed with RIC, you must be a licensed insurance Broker / Agent and carry Errors &
Omissions Insurance coverage.
Please complete and sign the enclosed Producer Data Sheet, Producer Agency Agreement and W-9 Tax ID
form.
The completed forms must be faxed to us with the following items:
1. Copy of your current Broker/Agent License
2. Agency License if applicable
3. Proof of Current Errors & Omissions Coverage
If you are located in one of these states we need:
• If you are in CA, or IL, we also need a copy of your bond
• If you are in WA, we need Affiliation form & credit card authorization form for $20. affiliation fee.
• If you are in NC, SC, NY we will need your broker license
An approved and signed appointment confirmation copy will be sent to you for your records.
We look forward to doing business with your agency.
Sincerely,
RIC Insurance General Agency
Fax all forms to 1-866-577-7595 Attention Agent Management.
RIC Insurance General Agency, Inc.
P.O. Box 12279, Santa Rosa, CA 95406
Phone: 888-693-7892 ♦ Fax: 866-577-7595
Website: www.ric-ins.com ♦ License #: 0482919
Producer Data Sheet
Agent Name: ______________________________________________________________
Agency DBA: _____________________________________________________________
Agency Corporation Name: ___________________________________________________
Legal Entity: Individual _____
Partnership _____
LLC _____
Corporation _____
Mailing Address: ___________________________ City_________________ State _____ Zip ________
Street Address: _____________________________ City _________________ State_____ Zip_________
Phone: _________________________________ Fax: ______________________________________
Social Security # ____ - ____ - _____ Federal Employer ID #____________________________
License Number: ______________________ Expiration Date: __________
E&O Coverage: Carrier________________ Policy Number: _____________ Expiration Date: __________
Broker Bond Filed: Yes ____ No ____
Time in Business: Years _____ Months ______
Corporate Officers Names:
1) ______________________________________
3) _______________________________________
2) ______________________________________
4) _______________________________________
Office Managers Name:
Name: __________________________________________ Phone: _____________________________
Agency E-mail Address: ________________________________________________________________
Policy Information E-mail Address: _______________________________________________________
Marketing Information E-mail Address: ____________________________________________________
Producers Names:
1) _________________________________
E-mail Address: _________________________________
2) _________________________________
E-mail Address: _________________________________
3) _________________________________
E-mail Address: _________________________________
4) _________________________________
E-mail Address: _________________________________
Insurance Companies You Represent: ____________________________________________________
____________________________________________________________________________________
MGA/Surplus Lines Brokers You Do Business With: ________________________________________
____________________________________________________________________________________
Completed by:_________________________________ Signature:______________________________
Date: __________________ Title: _______________________________________
PRODUCER AGREEMENT
with
RIC INSURANCE GENERAL AGENCY, INC.
This agreement is entered into on _______________________________ by and between
RIC INSURANCE GENERAL AGENCY, INC. (Herein after called the “General Agent”)
and _________________________ DBA: ___________________________________________
Agent /Broker license number: ____________________ with its principal office located at:
____________________________________________________________________________
(Herein after called the “Producer”)
Whereas the producer desires to offer business to the General Agent and the General Agent
desires to consider such offerings, now therefore, the Producer and the General Agent agree to
be bound by the following terms with respect to such offerings.
ARTICLE I: The producer agrees to pay the General Agent all premiums accruing on insurance
written under this agreement whether or not collected by the Producer from the insured. The
Producer shall not be entitled to credit for any flat cancellation until proof of such cancellation
satisfactory to the General Agent has been received by the General Agent, or unless prior express
agreement to such flat cancellation has been granted by the General Agent to the Producer.
ARTICLE II: The General Agent shall pay the Producer as commission a percentage of the
premium on each policy written and paid for under this Agreement at the rate stipulated by the
General Agent. The Producer shall pay the General Agent a return commission at the same rate
on any return premiums or cancellations ordered or made by the General Agent. RIC reserves the
right to accrue and defer, payment of commissions until a minimum of one hundred dollars
($100.) becomes due to Producer.
ARTICLE III: The General Agent expressly recognizes the independent ownership by the
Producer of the insurance business covered by this Agreement; however, in the event it is
necessary for the General Agent to cancel this Agreement for violation by the Producer, the
Producer relinquishes all rights or claims to subsequent renewals, additional premiums, or
commissions thereon insofar as may be necessary to satisfy the General Agent.
ARTICLE IV: The Producer agrees to cooperate fully with the General Agent to facilitate the
investigation and adjustment of any claim when and as requested by the General agent and under
any such rules and regulations as may be agreed upon from time-to-time.
ARTICLE V: Nothing in this Agreement shall be construed as limiting or restricting the right of
the General Agent to cancel any policy or policies or contracts of insurance issued under this
Agreement.
ARTICLE VI: The Producer shall not insert any advertisements respecting the General Agent in
any publication or issue any circular or paper referring to the General Agent without the consent
of the General Agent first obtained in writing. In case the General Agent shall be subjected to
loss or expense growing out of any such unauthorized or statement of the Producer, the Producer
shall be liable for all costs and damages arising there from.
ARTICLE VII: Except as may be provided by an addendum to this Agreement, the Producer has
no authority whatsoever to bind the General Agent or to accept any risk on behalf of the General
Agent.
ARTICLE VIII: This Agreement may be cancelled at any time by either of the parties hereto by
the giving of a written notice to the other.
ARTICLE IX: In the event the Producer holds only an agent’s license and it is necessary that a
sub-appointment be made: The Insurance Company agrees to license the Producer for the
express purpose of complying with the agency license laws of the state wherein the Agent
resides and in accordance with the agreement entered into by the agent, as Producer, and its
General Agent, but this Agreement shall confer upon the Agent no authority, express or implied,
to bind or obligate the Insurance Company in any respect, either as to risks being submitted for
consideration or as respects changes in the terms and conditions or any policy or binder issued
by the company or by its General Agent.
ARTICLE X: Additional premiums, which develop by audit or on reporting form policies will
be handled as follows: The Producer’s duty to pay the General Agent such additional premiums
will be satisfied within 45 days from the billing date. If the Producer is unable to collect the
premium due, he must request in writing that the premium be taken over for Direct Collection by
the Carrier within 45 days of the billing date. If Direct Collection is taken by the Carrier, the
Producer will forfeit all commissions on the premium collected by the Carrier. If the producer
fails to notify the General Agent within 45 days of the billing date, the producer will forfeit all
commissions.
ARTICLE XI: The Producer hereby grants permission to General Agent to communicate
pertinent information by facsimile or email to Producer.
The Producer acknowledges that he understands the limitations contained in this Agreement and
that no insurance submitted for consideration is effective until acceptance is indicated in writing
by the General Agent or the Carrier.
It is agreed the commissions or return commissions, as the case may be, shall be paid on
additional premiums collected, or on return premiums paid on adjustments, or on cancellations
made after the time of cancellation of the Agreement applying to any insurance for which an
original commission was allowed.
After the date of cancellation of this Agreement, unless otherwise stipulated at the option of the
General Agent, the Producer shall complete the collection and account to the General Agent for
all premiums or other transactions unaccounted for at the time of cancellation or arising
thereafter respecting insurance governed hereby.
IN WITNESS WHEREOF, this Agreement has been executed by the parties hereto, the day and
year first above named.
AGENT/BROKER Signature:_________________________________________
Please Print Name:__________________________________________________
General Agent’s Signature: ___________________________________________
Date: __________ Title: ____________________________________
W-9
Form
(Rev. December 2011)
Department of the Treasury
Internal Revenue Service
Request for Taxpayer
Identification Number and Certification
Give Form to the
requester. Do not
send to the IRS.
Print or type
See Specific Instructions on page 2.
Name (as shown on your income tax return)
Business name/disregarded entity name, if different from above
Check appropriate box for federal tax classification:
Individual/sole proprietor
C Corporation
S Corporation
Partnership
Trust/estate
Exempt payee
Limited liability company. Enter the tax classification (C=C corporation, S=S corporation, P=partnership) ▶
Other (see instructions) ▶
Address (number, street, and apt. or suite no.)
Requester’s name and address (optional)
City, state, and ZIP code
List account number(s) here (optional)
Part I
Taxpayer Identification Number (TIN)
Enter your TIN in the appropriate box. The TIN provided must match the name given on the “Name” line
to avoid backup withholding. For individuals, this is your social security number (SSN). However, for a
resident alien, sole proprietor, or disregarded entity, see the Part I instructions on page 3. For other
entities, it is your employer identification number (EIN). If you do not have a number, see How to get a
TIN on page 3.
Social security number
Note. If the account is in more than one name, see the chart on page 4 for guidelines on whose
number to enter.
Employer identification number
Part II
–
–
–
Certification
Under penalties of perjury, I certify that:
1. The number shown on this form is my correct taxpayer identification number (or I am waiting for a number to be issued to me), and
2. I am not subject to backup withholding because: (a) I am exempt from backup withholding, or (b) I have not been notified by the Internal Revenue
Service (IRS) that I am subject to backup withholding as a result of a failure to report all interest or dividends, or (c) the IRS has notified me that I am
no longer subject to backup withholding, and
3. I am a U.S. citizen or other U.S. person (defined below).
Certification instructions. You must cross out item 2 above if you have been notified by the IRS that you are currently subject to backup withholding
because you have failed to report all interest and dividends on your tax return. For real estate transactions, item 2 does not apply. For mortgage
interest paid, acquisition or abandonment of secured property, cancellation of debt, contributions to an individual retirement arrangement (IRA), and
generally, payments other than interest and dividends, you are not required to sign the certification, but you must provide your correct TIN. See the
instructions on page 4.
Sign
Here
Signature of
U.S. person ▶
Date ▶
General Instructions
Section references are to the Internal Revenue Code unless otherwise
noted.
Purpose of Form
A person who is required to file an information return with the IRS must
obtain your correct taxpayer identification number (TIN) to report, for
example, income paid to you, real estate transactions, mortgage interest
you paid, acquisition or abandonment of secured property, cancellation
of debt, or contributions you made to an IRA.
Use Form W-9 only if you are a U.S. person (including a resident
alien), to provide your correct TIN to the person requesting it (the
requester) and, when applicable, to:
1. Certify that the TIN you are giving is correct (or you are waiting for a
number to be issued),
2. Certify that you are not subject to backup withholding, or
3. Claim exemption from backup withholding if you are a U.S. exempt
payee. If applicable, you are also certifying that as a U.S. person, your
allocable share of any partnership income from a U.S. trade or business
is not subject to the withholding tax on foreign partners’ share of
effectively connected income.
Note. If a requester gives you a form other than Form W-9 to request
your TIN, you must use the requester’s form if it is substantially similar
to this Form W-9.
Definition of a U.S. person. For federal tax purposes, you are
considered a U.S. person if you are:
• An individual who is a U.S. citizen or U.S. resident alien,
• A partnership, corporation, company, or association created or
organized in the United States or under the laws of the United States,
• An estate (other than a foreign estate), or
• A domestic trust (as defined in Regulations section 301.7701-7).
Special rules for partnerships. Partnerships that conduct a trade or
business in the United States are generally required to pay a withholding
tax on any foreign partners’ share of income from such business.
Further, in certain cases where a Form W-9 has not been received, a
partnership is required to presume that a partner is a foreign person,
and pay the withholding tax. Therefore, if you are a U.S. person that is a
partner in a partnership conducting a trade or business in the United
States, provide Form W-9 to the partnership to establish your U.S.
status and avoid withholding on your share of partnership income.
Cat. No. 10231X
Form W-9 (Rev. 12-2011)
AGENCY INFORMATION SHEET
Agency Name: ___________________________________________
Have you worked with RIC, LTM or NWC recently? ____Yes ____No
How much premium does your agency write? _________________
Which carriers do you work with directly? MGAs? _________________________________________________
____________________________________________________________________________________________
How many producers does your agency have? ___________
Who makes daily decisions about which markets to use? Producers? CSRs? ______________________________
Of your total agency production, what percentage is Personal Lines _____% Commercial Lines____% ?
Do you specialize in any classes of business? ____Yes ____No
What lines of coverage do you write? ___________________________________________________________
Are you interested in joining a cluster group? ____Yes ____No
Are you currently with a cluster group? ____Yes ____No
What are they looking for in this type of relationship? _____________________________________________
What commissions are you paid? ______________________________________________________________
Do you pay access/membership fees? ____Yes ____No
Do you share in profit sharing? ____Yes ____No
What has your experience been like? _____ Excellent ______Good ______Fair _____Bad______ Never again!
Other comments:________________________________________________________________________________
Does your agency write Surplus Lines Business? ____Yes ____No
Who do you normally use? _______________________________________________________________________
What do you look for in a Surplus Lines Broker? ______________________________________________________
Do you presently use any online quoting systems? ____Yes ____No
Have you heard of our online quoting system called The Bind Zone? ____Yes ____No
Would you like to know more about The Bind Zone? ____Yes ____No