Agency Appointment Application Packet

This packet will help you fill out your Agency Appointment Application. The following documents are required: ☐ Agency Agreement – Signed and Dated ☐ Current Certificate of Insurance for professional liability at $1,000,000 coverage naming our carriers as certificate holder: Employers Compensation Insurance Company, Employers Insurance Company of Nevada, Employers Preferred Insurance Company and Employers Assurance Company. ☐ Signed IRS W-9 Form ☐ EMPLOYERS FCRA form(s) (if appointments are requested in: AL, AR, DC, FL, GA, KS, MN, MS, NJ, NM, NC, OK, SC, TN, VA, or WI)

All required documents must be fully and accurately completed. Key areas of the documents to complete are as follows:  Agency Appointment Application o Main Office Location Contact Data: Contact Data for this location will match the Street and Mailing Addresses on page 1. Please use additional sheets if necessary. o Office Location #2 Contact Data: Use this sheet if Office Location #2 is located in a different location from your Main Office Location. o Office Location #3 Contact Data: Use this sheet if Office Location #3 is located in at a different location from your other two offices.  E-Delivery Email – A few things to note with this option are below: o All of the following documents will be delivered electronically after enrollment: . All policy documents (i.e. New and Renewal) . Endorsements . Invoice Reminders . Cancellation Notices -- not available in all states*  In AZ, AR, CO, MN, NC, and SC, cancellation notices are required by law to be printed and mailed. . Reinstatement Notices o When you select the e-delivery option, you will have access to your clients' policy documents electronically through EACCESS, but your client will receive their policy documents in the mail—directly from EMPLOYERS. o You will automatically receive an e-mail when you have new client documents available.  Agency Agreement o Page 1 – First paragraph . Month, Day, Year and Legal Agency Name o Page 16 – If to Agency: . Address, City, State, Zip code

Insurance is offered through Employers Compensation Insurance Company, Employers Insurance Company of Nevada, Employers Preferred Insurance Company and Employers Assurance Company. EMPLOYERS does not do business in all jurisdictions. Please contact your local EMPLOYERS Territory Manager or visit www.employers.com for additional information. Agency Appointment Application . Attention: o Page 17 – FOR THE AGENCY BY: . Signed, Dated . Title of signatory o Page 20 – Agency Code of Conduct Acknowledgement . Write in any CONFLICTS OR POTENTIAL VIOLATIONS TO REPORT . If there are not any to report, please check the “NONE” box. . Agency Name . Agency Signature, Date . Print Name and Title:

Page 2 of 5 Revised 11/7/2016 Agency Appointment Application

Agency Data Legal Name of Individual or Agency: Fictitious name (dba): Federal Tax ID#:

Main Office Address: Street Address: Street City State Zip Code

Mailing Address: (if different from above) Street City State Zip Code

Agency E-mail: E-delivery E-mail: Agency Website: Phone Number: () Fax Number: () Primary Contact: Primary Contact E-mail:

Does your agency operate as traditional retail, wholesale/managing general, cluster, aggregator or other agency? If you are affiliated with a cluster or aggregator, please name the cluster or aggregator with which you are affiliated. Traditional/Re Wholesaler/M Cluster Aggregator Other tail GA ☐ ☐ ☐ If Other, please describe: How is your agency licensed? (i.e. agency, broker, surplus lines ☐ Agency broker) ☐ Broker ☐ Surplus Lines Broker

Licensing/Regulatory: Have you, any person employed by you, or your agency been subject Yes ☐ No ☐ to any disciplinary action within the past 10 years by a state insurance department or other regulatory authority. If yes, please explain (attach additional sheets if needed):

Is there any pending or threatened litigation or judgments within the Yes ☐ No ☐ past five years against the agency or any of its principals relating to the business activities of the agency or principals? If yes, please explain (attach additional sheets if needed):

Page 3 of 5 Revised 11/7/2016 Agency Appointment Application

Page 4 of 5 Revised 11/7/2016 Agency Appointment Application

Main Office Location Contact Data

Please list agency staff and identify who is licensed. Contact Phone E-mail Check if National Agency Name and Number Address Licensed Producer Principal/ Title Number Owner ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ Please attach completed FCRA authorization form if appointment is sought in the following states: AL, AR, FL, GA, IA, MN, MS, NJ, NM, NC, SC, TN, VA and WI.

Key Contact Information: S y s t e C m L C o M i o m a A c n m r d e t i k m n r s Contact Name Phone Number E-mail Address e i s a s ti n i c i n i n t o g s g s n t s r a t o r ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐

Page 5 of 5 Revised 11/7/2016 Agency Appointment Application ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐

*Please complete contact data information for each office location.

Page 6 of 5 Revised 11/7/2016 Agency Appointment Application

Appointments Requested: ☐ AL ☐ AR ☐ AZ ☐ CA ☐ CO ☐ CT ☐ DC ☐ FL ☐ GA ☐ IA ☐ ID ☐ IL ☐ IN ☐ KS ☐ KY ☐ MA ☐ MD ☐ MN ☐ MO ☐ MS ☐ MT ☐ NC ☐ NE ☐ NJ ☐ NM ☐ NV ☐ NY ☐ OK ☐ OR ☐ PA ☐ SC ☐ TN ☐ TX ☐ UT ☐ VA ☐ WI

Please return the following information for all office locations with your completed application. ☐ Agency Agreement – signed and dated ☐ Current Certificate of Insurance for professional liability ☐ Signed IRS W-9 Form ☐ EMPLOYERS FCRA form (if appointments are requested in: AL, AR, DC, FL, GA, KS, MN, MS, NJ, NM, NC, OK, SC, TN, VA, or WI)

I/We agree to permit Employers Assurance Company, Employers Compensation Insurance Company, Employers Insurance Company of Nevada and/or Employers Preferred Insurance Company (hereinafter “EMPLOYERS”) to conduct any investigation and contact any organization or individual who has any knowledge of our agency, the owners or principals, or any individuals employed by our agency as EMPLOYERS deems necessary to process this agency appointment application. This background investigation may include a financial investigation, credit history, review of public records, and/or inquiry to SIRCON. I/We agree to provide any authorizations, releases or other documents required by EMPLOYERS to conduct such investigation, upon request.

I represent and warrant that the information provided in this Agency Appointment Application is true and correct to the best of my knowledge. I understand that any incorrect, omitted or misrepresented information may result in termination of the appointment.

Print Name Signature Title Date

Submission of this application does not guarantee an appointment. Agency appointments are made at the sole discretion of Employers Assurance Company, Employers Compensation Insurance Company, Employers Insurance Company of Nevada and/or Employers Preferred Insurance Company.

Page 7 of 5 Revised 11/7/2016 Agency Appointment Application

Office Location #2 Contact Data

Legal Name of Individual or Firm: Fictitious name (dba): Street Address: Street City State Zip Code

Mailing Address: (if different from above) Street City State Zip Code

Will this office need its own Agency Code? ☐ Yes ☐ No

Please list agency staff and identify who is licensed. Contact Phone E-mail Check if National Agency Name and Number Address Licensed Producer Principal/ Title Number Owner ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ Please attach completed FCRA authorization form if appointment is sought in the following states: AL, AR, FL, GA, IA, MN, MS, NJ, NM, NC, SC, TN, VA and WI.

Key Contact Information:

Page 8 of 5 Revised 11/7/2016 Agency Appointment Application S y s t e C m L M C o

i a o m A c r n m d e k t i m n e r s Contact Name Phone Number E-mail Address i s t a s n i i c i i n n t o s g g s n t s r a t o r ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐

Office Location #3 Contact Data

Legal Name of Individual or Firm: Fictitious name (dba): Street Address: Street City State Zip Code

Mailing Address: (if different from above) Street City State Zip Code

Will this office need its own Agency Code? ☐ Yes ☐ No

Page 9 of 5 Revised 11/7/2016 Agency Appointment Application ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ Please attach completed FCRA authorization form if appointment is sought in the following states: AL, AR, FL, GA, IA, MN, MS, NJ, NM, NC, SC, TN, VA and WI.

Key Contact Information: S y s t e C m L M C o

Page 10 of 5 Revised 11/7/2016