ORTHEAST
AGENCIES, INC.
NEA Required Information Checklist:
Sub-Producer Agreement Print all 5 pages
Fill out pages 1 and 5 (see below instructions) Copy of your P&C License
ALFA Agent Enrollment
Welcome to Northeast Agencies!
Thank you for your interest in writing Commercial / Personal Lines (EQ) products through Northeast Agencies, Inc (NEA).
In order to enroll, agents are required to have print this entire packet.
Your submission can not be processed without the following items:
Agents are required to complete and fax the following documents to NEA:
Attention: Licensing Department Fax: (716) 954-0219
Alfa Insurance Agents Independent Agents Allstate Agents
ANPAC Agents
Enrollment Package
Agent Info
Commercial Lines Contact NEA
Service Center Contacts Carrier Service Centers Agent Address / Phone Change Book of Business Transfer Broker of Record Change ~ Under Construction
Personal Lines Commercial Lines
Office Locations
Personal Lines (not available in all states)
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www.NEAgencies.com
6467 Main Street, Suite 104 Williamsville, NY 14221 phone: (800) 333-0980 fax: (716) 954-0219
SUB-PRODUCER AGREEMENT
(Alfa Insurance Agent)
Northeast Agencies, Inc. (“NEA”), a New York corporation, having an office at 6467 Main Street, Suite 104, Williamsville, New York and _________________________________
having an office at ____________________________________________________________
(“Sub-Producer”), in consideration of the mutual covenants and agreements herein contained, agree as follows:
1. NEA hereby agrees to accept personal and commercial lines insurance from the Sub- Producer for the purpose of attempting to place it with an insurance carrier represented by NEA. The Sub-Producer represents and warrants that it is, and will be throughout the term of this Agreement, duly licensed to receive commissions and perform all obligations contemplated hereunder.
2. The activities of the Sub-Producer are limited to the following territory:
________________________________________________________________________
3. This agreement shall become effective on the date this agreement is duly executed by an authorized officer of NEA.
4. The Sub-Producer agrees to transact all business with NEA in accordance with all
applicable laws and Insurance Department rules and regulations, as well as guidelines and instructions now in force or hereafter issued by NEA.
5. During the term of this Agreement, NEA shall cause commissions to be paid to Sub- Producer through one or more insurance brokers affiliated with Alfa Mutual Insurance Company (the “Alfa Brokers”), as full compensation for all business submitted in
connection with this Agreement. In the event that any premiums are returned to the insured, the commission earned on that portion of the premiums so returned will be repaid.
6. Sub-Producer shall be granted access to the NEA website and related facilities for the purposes of supplying underwriting and rating information, and Sub-Producer agrees to access those facilities by following the instructions on the NEA website.
7. NEA will make available to Sub-Producer the NEA website (the “Site”) according to the following terms of use. By signing below, Sub-Producer agrees to be bound by these terms and conditions.
a. Only Sub-Producer and Sub-Producer’s authorized support staff are to use the Site.
Sub-Producer will immediately eliminate access to the Site by any individual who is no longer entitled to such access.
b. The Site is to be accessed and used only for legitimate business reasons. Sub- Producer and Sub-Producer’s authorized employees are responsible for maintaining the confidentiality of any access codes provided to Sub-Producer. Sub-Producer will
promptly report to the Northeast Licensing Department, at 1-800-333-0980, any unauthorized use of Sub-Producer’s access code or any other breach of security regarding Sub-Producer’s access code or the Site.
c. Sub-Producer and Sub-Producer’s employees must treat all customer information on the Site as strictly confidential and not use or disclose that information except for legitimate business purposes in compliance with all applicable privacy requirements.
Sub-Producer and Sub-Producer’s employees will also not use or disclose any of our confidential information except as expressly authorized by us in writing for
legitimate business purposes.
d. We reserve the right to terminate or suspend access to the Site or any related sites by any person or persons at any time, with or without cause.
e. We make no warranties with respect to the operation of or the information contained on the Site. We will not be liable for any damages, whether direct, indirect,
consequential, special or otherwise arising out of Sub-Producer’s use of the Site.
8. Sub-Producer agrees to follow the instructions on NEA’s website for submitting
underwriting and rating information, requesting a quote, requesting a binder or providing any other information as may be requested. Sub-Producer further agrees to maintain within the Sub-Producer’s files such appropriate documentation as may be required. NEA shall have the right to audit Sub-Producer’s books and records upon reasonable notice to ensure compliance with the terms and conditions of this Agreement.
9. The Sub-Producer acknowledges that for all funds received or collected in connection with business submitted or placed under this agreement it is therefore obligated to submit said funds to NEA in a timely manner and shall not, without the express written consent of the insured, or prospective insured, commingle such funds with its own funds held by it in any other capacity.
10. In the event any piece of business is bound and the policy is thereafter cancelled, for whatever reason, any earned premium resulting from such business shall be paid to NEA and/or the carrier issuing the policy by Sub-Producer directly or through one of the Alfa Brokers. Upon the payment of any earned premium pursuant to this provision, NEA agrees to assign to Sub-Producer any collection rights it has against the insured for any such earned premium.
11. Premiums on all policies placed by NEA on behalf of Sub-Producer shall be paid to NEA no later than the 30th day of the first month in which the policy or policies become effective or are shown on account current. This section applies only to those premiums paid directly to the Sub-Producer.
12. All monies due to NEA by Sub-Producer must be paid promptly on the due date. In the event the monies due to NEA are not paid by the due date, interest shall accrue at the rate of prime plus one percent (1%). Prime shall be defined as the Applicable Federal Rate then in- effect in accordance with the Internal Revenue Code and regulations. This section applies only to those premiums paid directly to the Sub-Producer.
13. The Sub-Producer shall report any insurance that is solicited to NEA by delivering such report directly to NEA or by depositing such report in the United States mail no later than the next business day following the day upon which any insurance is solicited. The Sub- Producer agrees to solicit and submit insurance policies as authorized and outlined by NEA’s Underwriting rules, guidelines and furnished manuals, instructions and bulletins.
THE SUB-PRODUCER FURTHER UNDERSTANDS AND ACKNOWLEDGES THAT IT DOES NOT HAVE ANY DIRECT, EXPRESS OR IMPLIED AUTHORITY TO BIND ANY INSURANCE COVERAGE ON BEHALF OF NEA OR ANY
COMPANY REPRESENTED BY NEA.
14. The Sub-Producer has no authority to: (a) make, alter, vary or discharge any contract; (b) extend a time for payment of premiums; (c) waive or extend any obligation or condition; (d) incur any liability on behalf of NEA; or (e) withhold any monies due or to become due to NEA.
15. If the Sub-Producer shall fail to report all business written by it or shall fail to pay to NEA premiums collected by it when due hereunder or shall otherwise breach this Agreement (any such event referred to as an “Event”), then all of its rights under this Agreement to
commissions on all premiums then unpaid to NEA shall thereby forthwith terminate and shall be held by NEA until a final accounting is performed with respect to the Sub-Producer.
Any commissions due to Sub-Producer may be held by NEA and applied to offset Sub- Producer’s obligations to NEA hereunder. Upon the occurrence of any such event, NEA shall have the exclusive right in its discretion and for its benefit to (i) collect any and all outstanding accounts receivable due to NEA on business written through NEA, (ii) solicit the renewal of any business previously written by NEA through the Sub-Producer, and (iii) sell or otherwise dispose of such renewals and expiration records relating thereto.
16. For Sub-Producer billed lines of insurance, the Sub-Producer shall be responsible for any additional premiums shown to be due under payroll, audits or otherwise and shall pay them to NEA within 20 days and will be billed under separate notice. If such payments are not paid within 20 days the Sub-Producer must notify NEA and NEA will have the option to return the premium for direct collection. If notice is not given within 20 days, then the Sub- Producer will be held responsible for the premium. If the premium is sent back for direct collection, then the Sub-Producer shall not be entitled to any commission thereon.
17. Audits and copies of the books and records of Sub-Producer with respect to business placed with NEA may be made by any duly authorized representative of NEA during normal business hours. NEA agrees to provide one (1) week advance written notice requesting access to such books and records.
18. The Sub-Producer shall not offer or pay rebates on any line of insurance covered by this Agreement, nor shall it accept any merchandise or service of any character in payment of premiums.
19. Neither party shall publish or issue any advertisement respecting the other without first obtaining the written consent of the other party.
20. All former contracts and/or agreements between the Sub-Producer and NEA are hereby cancelled and the producer shall hereafter act for NEA under this Agreement only.
21. The Sub-Producer shall promptly forward to NEA any information or documents regarding accidents, claims or suits that it may receive.
22. The waiver by either party of any breach, default, neglect or misconduct by the other party shall not be construed as a waiver of any of the terms, provisions or conditions hereof nor
shall such be construed as authority for the continuance of any such breach, default, neglect or misconduct.
23. Either party to this Agreement may terminate the same by giving 90 day notice to the other party in writing, and the power of the Sub-Producer to collect and receive premiums shall end with the termination of this Agreement, and the Sub-Producer will immediately return to NEA, or its duly authorized representative, a certified list of uncollected accounts, all unused supplies and other property of NEA. Upon termination, the Sub-Producer shall be entitled to commissions that are paid or payable as of the date of termination, and the Sub- Producer shall be entitled to commissions on insurance in force, or any renewal thereof, after the date of termination.
24. Each party agrees to indemnify and hold the other party harmless against all claims, loss, liability, cost and expense, including attorney’s fees, incurred by the indemnified party in connection with any error or omission , or the breach of this Agreement by, the
indemnifying party, or the enforcement of the indemnified party’s rights with respect thereto.
25. Sub-Producer acknowledges and agrees that it has received a material benefit by gaining access which it otherwise would not have to companies (each an “NEA Company”) with which NEA has a relationship by agency contract, Sub-Producer agreement, or other similar arrangement. During the term of this Agreement and for a period of one year following it, the Sub-Producer shall not, without the prior written consent of NEA, (i) knowingly pursue or accept a direct appointment from any NEA Company or (ii) knowingly attempt to broker such business through or to another agent or broker for the purpose of accessing an NEA Company.
26. This Agreement shall be binding on the Sub-Producer and the members, employees and agents of the Sub-Producer, who shall be deemed to have joined in this Agreement as if a party hereto. This Agreement is non assignable.
27. Sub-Producer acknowledges and agrees that it is an independent contractor and that nothing contained in this Agreement shall be deemed to create an employer/employee relationship.
28. This Agreement shall be governed by and construed in accordance with the laws of the State of New York, without regard to its conflict of laws rules. Any disputes arising out of or relating to this Agreement or the relationship created between the parties hereto shall be resolved in the Federal or State Courts of New York and venue shall be in Buffalo, New York. Sub-Producer hereby agrees and consents to the jurisdiction of any such courts.
29. This agreement constitutes the entire Agreement and understanding between the parties and supercedes and prior Agreement between the parties, whether written or oral. This
Agreement may not be modified or amended except in a writing signed by both parties hereto.
IN WITNESS WHEREOF, the parties hereto have executed this Agreement on the dates set forth below:
NORTHEAST AGENCIES, INC. SUB-PRODUCER
By: Brian Vrba, VP Agency Operations Print Name: ____________________________
Its: ______________________________ Signature: _____________________________
Date: _______/_______/_______ Date: _______/_______/_______
REQUIRED AGENCY INFORMATION
Agency Name: ________________________________________________________________
Address: _____________________________________________________________________
Street City State Zip
Phone: ______________________________ Social Security # _______________________
Fax: ________________________________ Tax ID # ______________________________
E-mail: ______________________________
License Number/s______________________
Alfa Agency Number/s: _________________
Please attach: Copy of State license/s
DATE: _________________________
IF YOU ARE THE AGENCY PRINCIPAL/OWNER, PLEASE COMPLETE SECTIONS 1,2 AND 3
IF YOU ARE NOT THE AGENCY PRINCIPAL/OWNER, PLEASE COMPLETE SECTION 2(AND SECTION 3, IF LICENSED)
**NOTE:ALL LICENSED AGENTS WITHIN THE OFFICE SHOULD COMPLETE AND RETURN THE FORM**
SECTION 1
NAME OF AGENCY (AS LICENSED): _________________________________________________________________________
DBA OR C/O (IF APPLICABLE): ____________________________________________________________________________
AGENCY FEDERAL TAX ID: _______________________________________________________________________________
AGENCY EMAIL ADDRESS: _______________________________________________________________________________
E&OCARRIER: ______________________________________________________________________________________
E&OPOLICY NUMBER: ______________________ E&OPOLICY LIMITS: ____________________________________
E&OPOLICY EFFECTIVE DATE: _________________ E&OPOLICY EXPIRATION DATE: ____________________________
STATES WHERE AGENCY IS LICENSED: ________________________________________________________________________
NAME OF INDIVIDUAL WHO WILL ACCESS AGENCY REPORTS ONLINE: __________________________________________________
EMAIL ADDRESS OF INDIVIDUAL: __________________________________________________________________________
APROFILE ADMINISTRATOR (WHO MAY OR MAY NOT BE THE AGENCY PRINCIPAL/OWNER) MAY BE DESIGNATED FOR YOUR AGENCY.
THIS IMPORTANT POSITION WILL CONTROL AND ADMINISTER THE SETUP OF EMPLOYEES IN YOUR OFFICE AND SUBPRODUCERS (IF APPLICABLE) WHO ARE GIVEN ACCESS TO YOUR POLICIES VIA MODERNLINK. THE PROFILE ADMINISTRATOR DETERMINES WHO WITHIN YOUR OFFICE WILL HAVE ACCESS TO POLICY INFORMATION (POLICY INQUIRY), FORMS (EFORMS) AND NEW BUSINESS QUOTING AND POLICY ISSUANCE FUNCTIONS (RATE/QUOTE &SUBMIT).
IPRINCIPAL (PRINTED NAME), __________________________________ DO HEREBY SPECIFY THAT THE FOLLOWING PROFILE
ADMINISTRATOR SHALL BE AUTHORIZED TO ACCESS THE AMERICAN MODERN AGENCY PORTAL FOR MY AGENCY:
LAST NAME: _________________________________ FIRST NAME: ______________________________________
PHONE NUMBER: _____________________________ EMAIL ADDRESS: ____________________________________
WILL THE PROFILE ADMINISTRATOR SET UP SUBPRODUCERS? YES NO
SEND THE LOGIN CREDENTIALS TO THE: PRINCIPAL PROFILE ADMINISTRATOR
AMERICAN MODERN INSURANCE GROUP IS FURTHER AUTHORIZED TO TRANSMIT THE CREDENTIALS FOR MY AGENCY VIA
UNENCRYPTED EMAIL TRANSMISSION TO THE FOLLOWING EMAIL ADDRESS: ________________________________________
SIGNATURE OF PRINCIPAL: __________________________________________ DATE: _______________________
A GENCY /A GENT S ETUP F ORM
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SECTION 2
LAST NAME: ____________________________________ FIRST NAME: _________________________________________
MIDDLE NAME: __________________________________ MAIDEN NAME: _______________________________________
GENDER: ______________________________________ DATE OF BIRTH: _______________________________________
NAME OF AGENCY (AS LICENSED): _________________________________________________________________________
PRINCIPAL/OWNER OF AGENCY: __________________________________________________________________________
OFFICE LOCATION ADDRESS: _____________________________________________________________________________
CITY: _________________________________________ STATE: ___________________ ZIP CODE: _________________
OFFICE MAILING ADDRESS (IF DIFFERENT FROM LOCATION ADDRESS): _________________________________________________
CITY: _________________________________________ STATE: ___________________ ZIP CODE: _________________
AGENCY PHONE #: ______________________________________ AGENCY FAX #: _________________________________
EMAIL ADDRESS: _____________________________________________________________________________________
IF YOU HOLD A VALID AGENT LICENSE, PLEASE COMPLETE THE FOLLOWING AND SIGN THE DISCLOSURE REGARDING
CONSUMER REPORTS ON PAGE 3:
RESIDENCE ADDRESS: __________________________________________________________________________________
CITY: _________________________________________ STATE: ___________________ ZIP CODE: _________________
SOCIAL SECURITY #: _______________________________ NPN(NATIONAL PRODUCER NUMBER): _______________________
LANGUAGES SPOKEN: ENGLISH SPANISH CHINESE VIETNAMESE
JAPANESE FILIPINO KOREAN OTHER ___________________________
STATES WHERE LICENSED: _______________________________________________________________________________
ANY ADDITIONAL COMMENTS FOR SETUP: ____________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________
PAGE 2
PLEASE SUBMIT COMPLETED FORM TO LICENSING &CONTRACTS: FAX:1-866-624-1921 E-MAIL: LICENSINGANDCONTRACTS@AMIG.COM
(REVISED 7/21/14)
SECTION 3
DISCLOSURE REGARDING CONSUMER REPORTS
Pursuant to the Fair Credit Reporting Act ("FCRA") (15 USC 1681b, 1681d), the following disclosure is required.
1. One or more of the affiliated companies of American Modern Insurance Group, Inc. (hereinafter
"Company") may obtain a consumer report regarding you for the purpose of determining whether to enter into an agency relationship and/or to appoint you as our agent.
2. If you are appointed as an agent, the Company may obtain consumer reports concerning you from time to time, and may use the consumer reports in deciding whether to continue, revoke, or terminate your appointment as an agent, or to otherwise change the terms of the agency relationship with you.
3. The types of consumer reports the Company may obtain with respect to you include criminal background checks and credit reports.
4. Please fill in the information below and sign to indicate that you agree that we may obtain a consumer report regarding you. Note that prior to taking any adverse action, a copy of your consumer report and a summary of rights will be sent to the address listed below (or, if no address is listed below, the address that we have on file).
Minnesota and Oklahoma residents only: If you would like a copy of the consumer report prepared on you, please check this box: □
California residents only: You may view the file on you by contacting Choicepoint (800-456-6004) or Employment Screening Associates (800-706-8848) during business hours. You may obtain a copy of this file at their office with proper ID and paying the costs to copy. You may be accompanied by one other person, provided that person has proper ID. You may make a written request to have your file sent to a specified address. Lastly, a summary of information will be provided by telephone, if you make a written request with the proper ID for disclosure.
Applicant's Statement Regarding Consumer Reports
I have received and read the Disclosure Regarding Consumer Reports above, advising me that the Company may obtain consumer reports about me. I understand that the Company is not permitted to obtain such consumer reports unless I authorize it to do so.
By signing below, I authorize the Company to obtain consumer reports about me. I authorize and direct each and every consumer reporting agency to provide consumer reports about me to the Company at its request.
Dated: __________________________________________________________
Signature of Applicant: _____________________________________________
Printed Name of Applicant: _________________________________________
Address: ________________________________________________________
City/State/Zip: ____________________________________________________
Agency Code: ____________________________________________________
Producer/Sub Number: _____________________________________________
PAGE 3 PLEASE SUBMIT COMPLETED FORM TO LICENSING &CONTRACTS:
FAX:1-866-624-1921 E-MAIL: LICENSINGANDCONTRACTS@AMIG.COM
