Federated National Underwriters Phone: (800) (option 4) N.W. 14 th Street, Suite 180 Fax: (954)

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1 AGENCY QUESTIONNAIRE Thank you for your interest in Federated National Underwriters representing Federated National Insurance Company and other nationally recognized insurance companies. Please complete the questionnaire below. Once we have received and reviewed your questionnaire and documentation, you will be notified of our decision. If you have any questions please contact us at: Federated National Underwriters Phone: (800) (option 4) Fax: (954) FIRM A. Legal Name of Firm: B. DBA: C. Street Address: City, State, Zip: County: D. Mailing Address: E. Address: F. Telephone: Fax: Corporation Partnership Individual Taxpayer ID No: 2. BACKGROUND A. Year Established: B. During the past 5 years, has the firm acquired / merged with another firm or has the firm changed names? Yes No If Yes, please explain: C. Is producer engaged in, owned by, associated or affiliated with, or controlled by any other business interest? Yes No If Yes, please explain: 3. PERSONNEL 12/12/2012 1

2 A. Principals, Officers, and Directors (list in order of % of ownership) Name Title/Position Address % Ownership % % % % Agent License # B. List producer s staff (not listed in (A)): Name Title/Position Address Agent License # Do you want s going to one (1) primary address? Yes If yes, which address? No 4. OPERATIONS A. Do you write business outside state of Florida? Yes No If Yes, please explain: 12/12/2012 2

3 B. Does your firm operate as a retailer, wholesaler, MGA, or combination? %Retail % Wholesale/Brokerage % MGA C. List State Licenses for all individuals: State Issued to License # Type of License ***Please attach copies of all your current licenses*** 5. PREMIUM VOLUME AND DISTRIBUTION A. Your total volume the last five years: 20 $ 20 $ 20 $ 20 $ 20 $ B. List major companies in order of premium volume Name Authority Years Represented Annual Volume Loss Ratio Binding 12/12/2012 3

4 C. Companies discontinued in the last five years & reason: D. Committed premium you will send to Federated National in the first 12 months: $ Need commitment on: 6. FINANCIAL A. Bank name: Phone: Number of personal lines policies per month Number of commercial lines policies per month Contact: B. Do you maintain E & O Coverage? Yes No Insurance Company: Limits: Deductible: ***Please attach copy of E&O Dec Page*** C. Has any member of your firm received any disciplinary action by a state insurance department or other regulatory authority? Yes No If Yes, please explain: D. Is there any pending or threatened litigation or augments within the past years exceeding $10,000 against the Agency or any of the Principals? Yes No The undersigned hereby declares that the answers given with respect to the foregoing questions are true, complete, and accurate with no misrepresentations, omissions or any other concealment of fact. Signature of Applicant: Printed Name and Title: Date: / / 12/12/12 4

5 CREDIT AND CHARACTER REPORT Please Print Name: Federated National Underwriters, Inc. ( Federated National Underwriters ), in considering your eligibility for, or maintenance or renewal of, an insurance agent s appointment or brokerage agreement with, will obtain and use information about you from a detailed credit and character report pursuant to Fla. Stat. Section AUTHORIZATION By signing below, you authorize Federated National Underwriters to obtain a detailed credit and character report about you for the purpose described above. This authorization will remain in effect until revoked by you in writing to: Federated National Underwriters, Inc., Attention Marketing; N.W. 14 Street, Suite 180, Sunrise, Florida You have the right to make a written request to the reporting agency to provide you with a complete and accurate disclosure of the nature and scope of any report about you obtained by Federated National Underwriters. Printed Name Date Social Security Number Date of Birth Home Phone Number Other names (including maiden name), if any, by which you have been known Current Address (include street, city, state and zip code): Name of Employer, if any Name of Federated National Underwriters Contract Relationship Manager, if known Signature 12/12/2012 5

6 All the locations you have lived during your adult lifetime (city & state only) All the locations you have worked during your adult lifetime (city & state only) Location of any high schools, colleges or graduate schools you may have attended (city & state only) 12/12/2012 6

7 FELONY AFFIDAVIT ACKNOWLEDGEMENT The federal Violent Crime Control and Law Enforcement Act of 1994 requires that no person 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 Federated National Underwriters, Inc. and to you; therefore, as a condition of your producer relationship with Federated National Underwriters, Inc., 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. Name Social Security Number Date of Birth Date Producer Code Agency Name Signature 12/12/2012 7

8 Form W-9 (Rev. December 2011) Department of the Treasury Internal Revenue Service Name (as shown on your income tax return) 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. 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. Note. If the account is in more than one name, see the chart on page 4 for guidelines on whose number to enter. Social security number 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 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. Date 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 ). 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 X Form W-9 (Rev )

9 QUESTIONNAIRE CHECKLIST PLEASE VERIFY THAT YOU HAVE SIGNED AND INCLUDED THE FOLLOWING: Agency Questionnaire signed Felony Affidavit Acknowledgment (all 220 agents who will be signing our applications need to sign an affidavit) Credit and Character Report (all 220 agents who will be signing our applications need to sign a Disclosure & Authorization) Copy of each agent s Florida Insurance License W-9 E&O Declaration Page IMPORTANT: Personal Umbrella and Flood polices must be paid in full Homeowners and Workers Compensation policies can be paid in full or have available payment plans. Commercial General Liability, Commercial Auto and Inland Marine policies have two set up options Please see below and initial which you would like. DIRECT BILL: This set up option gives your agency the most flexibility; policies can be A) Direct Billed, B) Premium Financed or C) Paid in Full. A) DIRECT BILLED: With this option, the gross collected premiums will be swept via ACH from the agency s bank account five days after the binding of the policy. Please make sure the clients are making the checks out to the agency, as the company will be directly withdrawing funds from your agency s bank account. Commissions are paid to the agency via ACH when the commission statements are generated on the 1 st and the 15 th of every month. They are available to view at FedNat.com. B) PREMIUM FINANCED: When you choose to premium finance a policy, the net down payment will be swept via ACH from the agency s bank account five days after the binding of the policy by the Premium Finance Company (PFC). The system will then automatically send monies from the PFC to Federated National Insurance Company; a draft is NOT necessary. PFC s that appear on your drop down menu are 12/12/2012 8

10 contracted with True Premium AND contracted with your agency. Please follow the PFC s submission guidelines after a PFC contract is generated. C) PAID IN FULL: If a policy is paid in full at the agency, the net premium will be swept via ACH from your agency s bank account five days after the binding of the policy. If your agency is set up as Direct Bill, Federated National will directly mail a renewal offer via U.S. Postal Service to your insured. Once the renewal policy is paid, you will be credited your commission on the following agency statement. NET PAYMENT WITH APPLICATION: With this option, the total amount of premiums less your commission will be submitted via an agency check or premium finance draft. The agent s bank account will not be swept for premiums (If you write commercial auto, your account will be swept for the MVR fees only). The agent will keep the commission up front. Applications and monies must be submitted to underwriting within five days after binding the policy. Date of Visit: DO NOT COMPLETE BELOW INTERNAL USE ONLY Does agency have a professional store front? If commercial lines producer: A. Did you explain the difference between Direct Bill and PFC Net? B. Did you explain the MVR reimbursement function? General Comments: Do you recommend appointment? Marketer Name: 12/12/2012 9