Progressive Carrier Profile - Typepad · 2012-06-06 · below and the depository named below for payment of settlements due to Progressive by the agency or for payment of settlements

Progressive Carrier Profile

Type of Billing: Direct Bill Download to Instar: Yes How to Quote: Carrier Website, EZ Lynx EZ Lynx Integration: Yes

Geographic Restrictions: None

Market Lines of Business and Gross Commissions:

• Personal Auto 10.0% New / 10.0% Renewal • Commercial Auto 10.0% New / 10.0% Renewal • Watercraft 10.0% New / 10.0% Renewal • Motorcycle 15.0% New / 10.0% Renewal • Travel Trailer 10.0% New / 10.0% Renewal

Type of Appointment: Integra Sub Agent Code

Commission Paid As – Sub Location Code (Please refer to your commission exhibit for a detailed definition)

Progressive offers sub appointments to Integra Partner Agents immediately with no required PIF count.

Appointment Documents Required:

1. Additional Location Form 2. Premium Sweep Authorization 3. Progressive Felony Form 4. Progressive FCRA Form 5. W9 (Integra Signed – include with your other forms)

Appointment Process/Instructions:

1. Complete all forms. 2. Email completed forms to [email protected] 3. Please list the subject line of your email “New Integra Appointment Request - (Name of

Producer)”.

Most Progressive appointments take 3 weeks to process from the time that you submit your email assuming all forms are complete.

EXPRESS TRANSFER AUTOMATED CLEARING HOUSE AUTHORIZATION

The Progressive Group of Insurance Companies (Progressive) is hereby authorized to present Express transfer items (posting credit and debit entries) with the agency’s bank account indicated below and the depository named below for payment of settlements due to Progressive by the agency or for payment of settlements due to the agency by our company.

The undersigned represents that s/he is an authorized signer on this account.

This arrangement does not affect the agency’s primary obligation for payment. This authorization is to remain in effect until we are notified in writing to the contrary.

1. ______________________________________________________________________________________ Bank Name and Branch (or Main Office) Bank Phone Number

2. ______________________________________________________________________________________ Bank Address (street, city, state, zip)

3. ______________________________________________________________________________________ Name/Title on Bank Account

4. ______________________________________________ 5.______________________________________________ Checking Account Number (from check) Bank Routing Number (from check)

6. _____________________________________________ 7._____________________________________________ Agency Name Agency Code

8. _______________________________________________________________________________________________ Agency Contact Person and Telephone Number

9. ___________________________________________________ 10._______________________________________ Authorized Signature on the Account Date

11. __________________________________________ 12. _______________________________________________

Agency Audit Contact Person Bank Fee for returned deposit item 13. __________________________________________ 14. _______________________________________________

Name of Progressive Territory Sales Manager Effective date for account changes

If this is a change from an existing account, please indicate effective date of change.

Express Money transfer is a Progressive product to transact electronic funds transfer via the Automated Clearing House (ACH) network.

EXPRESS TRANSFER AUTOMATED CLEARING HOUSE AUTHORIZATION

Before using EXPRESS, you must complete an authorization form. This form authorizes the electronic transfer of funds for payment or credit on your bank account.

The authorization form also provides Progressive with the necessary details to process EXPRESS transactions.

Please attach a voided or cancelled bank check to this form so that Progressive can retain the bank account and routing information.

Fax the authorization form, along with the voided or cancelled check, to a Progressive Agency Licensing Coordinator at 1-888-316-0107.

INSTRUCTIONS FOR COMPLETING THE AUTHORIZATION FORM

1. Bank name and branch: provide the name of the bank where your account is located. Also, indicate whether your bank is a branch office or the main office. The bank phone number is also needed.

2. Bank address: indicate the street, city, state, and ZIP code of your bank.

3. Name/title on bank account: provide the legal name on the account, i.e., The ABC Agency.

4. Checking account number: indicate your bank account number. This is usually the last set of numbers on the bottom of your check.

5. Routing number: if you attached a bank deposit slip, please verify that the routing number is the same as the one on your checks.

6. Agency name: provide your agency’s full legal name.

7. Agency code: provide the agency code for which Express transactions are authorized. (Note: If there are multiple agency codes for this particular bank account, please list them all.)

8. Agency contact person and telephone number: provide the name and telephone number of someone in your agency who is familiar with Express transactions, in the event we need to contact you.

9. Authorized signature on the account.

10. Date: Please list the date that you sign the document.

11. Agency audit contact person: name of the agency contact person who will handle file audits between Drive Insurance and the agency.

12. Bank fee for returned deposit item: The amount your bank charges when an item is returned for special handling. (Amount is typically between $10 or less, and is not related to an NSF overdraft charge.)

13. Name of Progressive’s territory sales manager.

14. Effective date for account changes.

Felony AFFidAvit Acknowledgement

The federal Violent Crime Control and Law Enforcement Act of 1994 requires that no person who has been convicted of a felony involving “dishonesty” or “a breach of trust” participate in the “business of insurance”. Criminal penalties for violation of the Act apply to Progressive and to you, and therefore, as a condition of your producer relationship with Progressive, you are required to answer the following question:

Have you ever been convicted of a felony involving “dishonesty or “a breach of trust”?

YES, I have been convicted of a felony involving “dishonesty or “a breach of trust”

NO, I have not been convicted of a felony involving “dishonesty or “a breach of trust”

Date:

Name:(As shown on your resident license)

Other Names:(including maiden name), if any, by which you have been known

Social Security #: Date of Birth:

Agent Code:

Agency Name:

Signature:

090901 FelonyAffidavit-03 kab

FAIR CREDIT REPORTING ACT DISCLOSURE & AUTHORIZATION

Please print, sign and fax to Progressive’s Secured Fax Number 1-888-316-0107

Please read the following and indicate your agreement by signing below.

Please Print Name: ______________________________________________________________________

Progressive Casualty Insurance Company or its affiliates (“Progressive”), in considering your eligibility to act as an independent agent on behalf of Progressive, will attempt to obtain and use information about you from “consumer reports.”

A “consumer report” is any written, oral or other communication of any information by a consumer reporting agency bearing on a consumer’s credit worthiness, credit standing, credit capacity, character, general reputation, personal characteristics, or mode of living, which is used or collected for the purpose of serving as a factor in establishing the consumer’s eligibility for employment purposes. It includes an “investigative consumer report,” which contains information concerning a consumer’s character, general reputation, or personal characteristics obtained through personal interviews with persons who may have knowledge concerning such items of information.

If Progressive takes an adverse action based on information in a consumer report about you, then Progressive will notify you of the adverse action and identify the consumer reporting agency that furnished the report. For 60 days following receipt of the notice, you will have a right to obtain a free copy of the consumer report and dispute with the consumer reporting agency the accuracy or completeness of any information in it.

You are also free to contact the Federal Trade Commission about your rights under the Fair Credit Reporting Act (“FCRA”). You may request in writing that Progressive disclose the nature and scope of any investigative consumer report and provide a written summary of your rights under the FCRA.

AUTHORIZATION

By signing below, you authorize Progressive to obtain “consumer reports” about you for purposes of determining your eligibility to act as an independent agent on behalf of Progressive. This authorization includes the release to Progressive of your residence address and other information in any state Department of Motor Vehicle’s records, and you hereby waive the application requirements of Section 1808.21 of the California Vehicle Code to the extent it would prohibit the release of such information. This authorization shall remain on file and serve as an ongoing authorization for Progressive to procure consumer reports about you at any time while you are acting as an independent agent on behalf of Progressive.

If you live in New York: You have the right to inspect and receive a copy of any investigative consumer report requested by Progressive by contacting EmployeescreenIQ (or such other consumer reporting agency as may be identified by Progressive) directly.

Check this box if you wish to be informed whether a consumer report was requested and the name and address of the consumer reporting agency. Even if you do not check this box, you may request this information at any time by contacting Progressive at: Attention BIU; 6300 Wilson Mills Road, Box N71A, Mayfield Village, OH 44143.

122909 FairCreditAct

If you live in California:

Unless you check this box, we will provide to you a copy of public records that Progressive may obtain about you. Check this box if you do not wish to receive a copy of these records. Unless otherwise notified by Progressive, the source of any investigative consumer report (as that term is defined under California law) will be EmployeescreenIQ, P.O. Box 22627, Cleveland, OH 44122-0627, 1-800-235-3954.

If you live in Minnesota:

You have the right to make a written request to the consumer reporting agency to provide you with a complete and accurate disclosure of the nature and scope of any consumer report about you obtained by Progressive. Check this box if you wish the consumer reporting agency to provide this disclosure.

If you live in California, Minnesota, or Oklahoma:

You have the right to request at no charge, a copy of any consumer reports obtained by Progressive about you. Check this box if you wish to receive a copy of the consumer reports.

Note: If you check this box, Progressive will request the consumer reporting agency to directly mail to you a copy of any consumer reports.

Date: ______________________________

Name: _________________________________________________________________________________________ (As shown on your resident license)

Other Names: _________________________________________________________________________________________

(including maiden name), if any, by which you have been known)

Social Security #: _________________________________________________ Date of Birth: _________________________

Current Residence: _________________________________________________________________________________________

City: _________________________________________________ State: _________________ Zip: ___________

Phone: _________________________________________________

Signature: _________________________________________________________ Agency Code: ________________

Locations of any high schools, colleges or graduate schools you may have attended (city & state only)

All the locations you have worked during your adult lifetime (city & state only)

All the locations you have lived during your adult lifetime (city & state only)

122909 FairCreditAct