P.O. Box 14770, Scottsdale, AZ 85267-4770 • (480) 991-7889 • (800) 848-8860 • FAX (480) 948-1394
P.O. Box 571770, Murray, UT 84157-1770 • (801) 290-1144 • (800) 594-8900 • FAX (801) 290-1160
Dear Producer,
Thank you for your interest in placing business through Colonial General Insurance Agency, Inc.
Attached is your Producer/Broker agreement, but before you sign the attached agreement, we want to make sure you
understand that you are entirely responsible for the collection of all premiums when you request coverage to be bound. There
are no flat cancellations and all policies are subject to a minimum earned premium.
Policies that are premium financed will require the down payment, which consists of 25% of the pure premium and all taxes
and fees, along with a signed financed agreement. E-mail our in-house affiliate Sundance Premium Finance Co. at
sundance@colgen.com to set up your financing online.
We look forward to doing business with your agency.
I have read the above and understand that I am responsible to collect all premiums from the insureds.
Agency Name Date
P.O. Box 14770, Scottsdale, AZ 85267-4770
8475 E. Hartford Dr., Scottsdale, AZ 85255
(480) 991-7889 WATS (800) 848-8860 FAX (480) 948-1394
P.O. Box 571770, Murray, UT 84157-1770
849 W. Levoy Dr., Suite 230, Taylorsville, UT 84123
(801) 290-1144 WATS (800) 594-8900 FAX (801) 290-1160
PRODUCERS BROKERAGE QUESTIONNAIRE
Agent/Agency Name
(If using a company name must be licensed accordingly)
Mailing Address: City: State: Zip:
Street Address: City: State: Zip:
Bus. Phone: E-mail: Fax:
Preferred Correspondence Method: E-mail Fax Mail
Individual Sole Ownership Social Security Number:
Corporation Partnership Tax I.D. Number:
Principal’s Name: Title:
Principal’s Name: Title:
Principal’s Name: Title:
Accounting Manager or Contact:
Bank Premium Trust Account at: Name
Location
E & O Policy Number: Limits: Company:
Please list other states you are licensed to write business in:
ALL LICENSED AGENTS & BROKERS MUST BE LISTED ON REVERSE
MARKETING INFORMATION
In order to serve you better, we have compiled the following questions to be used for marketing purposes. Once your appointment is
complete, we will be sending you marketing packets. Please answer the following questions so we can send you the appropriate
information.
Agency Name___________________________________ Contact Phone No.__________________________
Current companies in office (top three): Check the Lines of Business your agency writes:
1.
Personal Lines
Commercial Lines
Professional Lines
2.
Personal Lines
Commercial Lines
Professional Lines
3.
Personal Lines
Commercial Lines
Professional Lines
What Lines of Business does your agency specialize in?
1.__________________________________________________________________________________________________________
2.__________________________________________________________________________________________________________
3.__________________________________________________________________________________________________________
Dated:_______________________________________
CURRENT COPY OF ALL LICENSES MUST BE ATTACHED
Company or Organization License Name:
Affiliate’s Name
Position
Direct Phone: Direct Fax: E-mail:
Please Check Affiliate’s Preferred Method of Correspondence
Affiliate’s Name
Position
Direct Phone: Direct Fax: E-mail:
Please Check Affiliate’s Preferred Method of Correspondence
Affiliate’s Name
Position
Direct Phone: Direct Fax: E-mail:
Please Check Affiliate’s Preferred Method of Correspondence
Affiliate’s Name
Position
Direct Phone: Direct Fax: E-mail:
Please Check Affiliate’s Preferred Method of Correspondence
Affiliate’s Name
Position
Direct Phone: Direct Fax: E-mail:
Please Check Affiliate’s Preferred Method of Correspondence
Affiliate’s Name
Position
Direct Phone: Direct Fax: E-mail:
Please Check Affiliate’s Preferred Method of Correspondence
Affiliate’s Name
Position
Direct Phone: Direct Fax: E-mail:
Please Check Affiliate’s Preferred Method of Correspondence
Affiliate’s Name
Position
Direct Phone: Direct Fax: E-mail:
Please Check Affiliate’s Preferred Method of Correspondence
Page 1 of 3
PRODUCERS BROKERAGE AGREEMENT
THIS AGREEMENT, made this ________ day of _______________, _______ between
Colonial General Insurance Agency, Inc., Scottsdale, Arizona, hereinafter referred to as
“General Agent”, and ___________________________________________________________
of the State of ___________________ , hereinafter referred to as “Producer” and whose
address is ___________________________________________________________________.
WITNESSETH THAT:
I. GENERAL AGREEMENT:
Pursuant to request that underwriting facilities of the General Agent to be made available to the
Producer, the General Agent agrees to give consideration to proposals for insurance covering
risks located in those states in which General Agent has lawful authority, subject to restrictions
placed upon such Producer by the laws of State(s) in which said Producer is authorized to write
insurance business and further subject to the following terms, limitations and conditions which
are mutually agreed upon between the General Agent and the Producer.
II. LICENSE:
The Producer warrants that he is properly licensed for the classes of business to be conducted
and for the lines of coverage to be procured through the facilities of the General Agent.
III. BINDING AND COMMISSIONS:
The General Agent shall allow the Producer a commission as specified in the Schedule
attached. In the event the General Agent shall issue policies on Classes of Risk other than
those shown, the rate of commission thereon shall, in the absence of prior mutual agreement, to
be fixed by the General Agent. Coverage on Dwelling Fire and Mobile Home with values of
$100,000 or less, may be bound by the producer the date following the date postmarked. In
case of metered mail, coverage will be deemed bound on the day the application reached the
General Agent’s office. All other binders shall be issued by the General Agent.
IV. PAYMENT OF PREMIUMS:
All premiums received by the Producer shall be held by Producer in trust for the General Agent,
as Trustee, until payment thereof is made to the General Agent. The privilege of retaining
commissions out of such premiums, the keeping of an account with the Producer on the
General Agent’s book as creditor and debtor account, alteration in commission or other
compensation rate, compromise, settlement of declaration of Balance due shall not be held to
waive assertion of such trust relationship. Unless the Producer has been authorized in writing
to pay on an account current basis, any and all premium must be paid by the Producer to the
General Agent prior to the issuance of any binder by the General Agent. If the producer has
been authorized to pay on an account current basis, the payment of any and all premium due
the General Agent shall be made within fifteen (15) days from the last day of the month
following the date of the monthly statement rendered by General Agent.
V. CANCELLATIONS – Effective Date:
Notwithstanding the return of an original policy for cancellation, such cancellation shall not be
effective until sufficient time has elapsed for proper notice to mortgagors, loss payees,
certificate holders, public utility regulatory bodies or similar entities, in cases where such notice
is required.
Page 2 of 3
VI. EXPIRATION NOTICES:
Any custom or usage to the contrary notwithstanding, the General Agent shall be under no
obligation to give the Producer notice of expiration of any policies of insurance which the
Producer may procure through the facilities of the General Agent.
VII. LOSS AND CLAIMS:
This agreement confers upon the producer no authority to handle, adjust or apportion losses or
claims. However, the Producer agrees that in the event of an accident, occurrence, loss or
similar event that might give rise to a claim that is reported to him by an Insured of a Company
represented by the General Agent, or by a party on behalf of such an Insured, the Producer
shall immediately forward all information, including, but not limited to reports, verbal or written,
summonses and complaints and any other legal documents given to Producer, to the General
Agent. Any and all information of this type shall be reported by the Producer to the General
Agent as soon as reasonably possible, and in no event later than (3) days from the date of
receipt thereof by the Producer.
VIII. EARNED PREMIUMS:
In the event of cancellation of insurance written hereunder, the Producer guarantees to pay to
the General Agent an earned premium on business accepted by the General Agent for such
time as coverage remains in force.
IX. OWNERSHIP OF EXPIRATIONS:
Both parties to this Agreement recognize the ownership by the Producer of the insurance
business covered by this Agreement. In the event the Producer fails to pay any sum due the
General Agent by virtue of any policy or endorsement procured by the General Agent, the
Producer hereby assigns to the General Agent as security, but not in payment therefor, all sums
due or to become due Producer from the insured(s) for whom such contract of insurance or
endorsement was procured, with the full authority of the General Agent to demand and collect
the same directly. On premium so collected by the General Agent, Producer shall be entitled to
no commissions. The Producer further grants to the General Agent a security interest in and to
all of Producer’s records of expirations, of policies or contracts of insurance produced under or
by virtue of this Agreement, including the ownership, use and control thereof, with the right of
the General Agent to take possession of the same and have all of the rights of a holder of a
security interest granted by law, so long as the Producer is indebted to the General Agent for
any sum of money due under any insurance contract produced under or by virtue of this
Agreement.
X. INDEPENDENT CONTRACTOR:
The General Agent shall not be responsible for the Producer’s expenses such as rentals,
transportation facilities, clerk hire, solicitor’s fees, postage, advertising, exchange, personal local
license fees, or any other expenses whatsoever. Any policy forms and other like supplies
furnished to the Producer by the General Agent shall always remain property of the General
Agent and shall be returned to the General Agent promptly upon demand. Neither the term
“Producer” nor anything contained herein or in any of the bylaws, rules or regulations of the
General Agent shall be construed as creating the relationship of employer and employee
between the General Agent and the Producer. The Producer, as an independent contractor,
shall be free to exercise his own discretion and judgement with respect to the persons, firms, or
corporations, from which the Producer will solicit business except with respect to the direct bill
policies. The Producer shall have sole responsibility to notify Insured of policy expirations and
solicitation of renewals.
Page 3 of 3
XI. RESPONSIBILITY:
In the event the Producer under this Agreement is a corporation, it is understood, agreed, and
unconditionally guaranteed by the undersigned individuals, principal stockholders and directors
of said corporation, that all conditions of the Agreement and any supplement, amendment
extension, addenda or renewal thereof shall be binding upon them severally and jointly in the
same manner as upon the corporation named herein as Producer.
XII. RENEWAL BILLINGS:
All renewals will be agency billed, except for renewals billed by the general agent through
automation at request of Producer.
XIII. ERRORS & OMISSIONS COVERAGE:
The Producer agrees to maintain an active Errors & Omission policy with minimum limits of at
least $1,000.000.00 and agrees to furnish the General Agent a copy of the renewal annually.
XIV. COMPLETE AGREEMENT:
This Agreement supersedes all former Agreements and contains the full and complete
Agreement between the parties hereto. It may be amended only by subsequent written
agreement and oral representations, if any, shall have no force and effect.
XV. TERMINATION OF AGREEMENT:
This agreement may be terminated by either party by giving the other written notice of such
termination by U.S. Mail at the last known address. The Agreement will terminate immediately if
either party loses its authority or license to operate lawfully under the laws of any state or
regulatory authority or body or upon failure of the Producer to remit payment to the General
Agent under the terms set out in this Agreement.
XVI.
Upon request to bind coverage, I understand as Producing Broker that I am fully responsible for
payment of Premium to General Agent, whether or not payment has been received from the
Insured.
Producer:___________________________Printed Name:____________________________
Signature
Signed in Scottsdale, Arizona Colonial General Insurance Agency, Inc.
This______ day of ___________, ____ Signature___________________________
Witness: ________________________
Signed in ________________________ ___________________________________
(Print Name of Producer)
This______ day of ___________, ____ Signature___________________________
Witness: ________________________ Title: ______________________________
Signature___________________________
Title:_______________________________
NOTE: If Producer is Corporation or Partnership, all principals or general partners must sign.
INSTRUCTIONS TO PRINTERS
FORM W-9, PAGE 1 of 4
MARGINS: TOP 13mm (
1
2 "), CENTER SIDES. PRINTS: HEAD to HEAD
PAPER: WHITE WRITING, SUB. 20. INK: BLACK
FLAT SIZE: 216mm (8
1
2 ") 3 279mm (11")
PERFORATE: (NONE)
Give form to the
requester. Do not
send to the IRS.
Form
W-9
Request for Taxpayer
Identification Number and Certification
(Rev. October 2007)
Department of the Treasury
Internal Revenue Service
Name (as shown on your income tax return)
List account number(s) here (optional)
Address (number, street, and apt. or suite no.)
City, state, and ZIP code
Print or type
See Specific Instructions on page 2.
Taxpayer Identification Number (TIN)
Enter your TIN in the appropriate box. The TIN provided must match the name given on Line 1 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
or
Requester’s name and address (optional)
Employer identification number
Note. If the account is in more than one name, see the chart on page 4 for guidelines on whose
number to enter.
Certification
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
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
2.
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
Form W-9 (Rev. 10-2007)
Part I
Part II
Business name, if different from above
Cat. No. 10231X
Check appropriate box:
Under penalties of perjury, I certify that:
13
I.R.S. SPECIFICATIONS
TO BE REMOVED BEFORE PRINTING
DO NOT PRINT — DO NOT PRINT — DO NOT PRINT — DO NOT PRINT
TLS, have you
transmitted all R
text files for this
cycle update?
Date
Action
Revised proofs
requested
Date
Signature
O.K. to print
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.
3.
I am a U.S. citizen or other U.S. person (defined below).
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.
Individual/Sole proprietor
Corporation
Partnership
Other (see instructions)
©
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.
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
Definition of a U.S. person. For federal tax purposes, you are
considered a U.S. person if you are:
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.
The person who gives Form W-9 to the partnership for
purposes of establishing its U.S. status and avoiding withholding
on its allocable share of net income from the partnership
conducting a trade or business in the United States is in the
following cases:
The U.S. owner of a disregarded entity and not the entity,
Section references are to the Internal Revenue Code unless
otherwise noted.
A domestic trust (as defined in Regulations section
301.7701-7).
Limited liability company. Enter the tax classification (D=disregarded entity, C=corporation, P=partnership)
©
Exempt
payee
Purpose of Form
INSTRUCTIONS TO PRINTERS
FORM W-9, PAGE 2 of 4
MARGINS: TOP 13 mm (
1
2"), CENTER SIDES. PRINTS: HEAD to HEAD
PAPER: WHITE WRITING, SUB. 20. INK: BLACK
FLAT SIZE: 216 mm (8
1
2") 3 279 mm (11")
PERFORATE: (NONE)
Form W-9 (Rev. 10-2007)
Page 2
Sole proprietor. Enter your individual name as shown on your
income tax return on the “Name” line. You may enter your
business, trade, or “doing business as (DBA)” name on the
“Business name” line.
13
I.R.S. SPECIFICATIONS
TO BE REMOVED BEFORE PRINTING
DO NOT PRINT — DO NOT PRINT — DO NOT PRINT — DO NOT PRINT
Other entities. Enter your business name as shown on required
federal tax documents on the “Name” line. This name should
match the name shown on the charter or other legal document
creating the entity. You may enter any business, trade, or DBA
name on the “Business name” line.
If the account is in joint names, list first, and then circle, the
name of the person or entity whose number you entered in Part I
of the form.
Specific Instructions
Name
Exempt Payee
5. You do not certify to the requester that you are not subject
to backup withholding under 4 above (for reportable interest and
dividend accounts opened after 1983 only).
Certain payees and payments are exempt from backup
withholding. See the instructions below and the separate
Instructions for the Requester of Form W-9.
Civil penalty for false information with respect to
withholding. If you make a false statement with no reasonable
basis that results in no backup withholding, you are subject to a
$500 penalty.
Criminal penalty for falsifying information. Willfully falsifying
certifications or affirmations may subject you to criminal
penalties including fines and/or imprisonment.
Penalties
Failure to furnish TIN. If you fail to furnish your correct TIN to a
requester, you are subject to a penalty of $50 for each such
failure unless your failure is due to reasonable cause and not to
willful neglect.
Misuse of TINs. If the requester discloses or uses TINs in
violation of federal law, the requester may be subject to civil and
criminal penalties.
If you are an individual, you must generally enter the name
shown on your income tax return. However, if you have changed
your last name, for instance, due to marriage without informing
the Social Security Administration of the name change, enter
your first name, the last name shown on your social security
card, and your new last name.
If you are exempt from backup withholding, enter your name as
described above and check the appropriate box for your status,
then check the “Exempt payee” box in the line following the
business name, sign and date the form.
4. The IRS tells you that you are subject to backup
withholding because you did not report all your interest and
dividends on your tax return (for reportable interest and
dividends only), or
3. The IRS tells the requester that you furnished an incorrect
TIN,
2. You do not certify your TIN when required (see the Part II
instructions on page 3 for details),
You will not be subject to backup withholding on payments
you receive if you give the requester your correct TIN, make the
proper certifications, and report all your taxable interest and
dividends on your tax return.
1. You do not furnish your TIN to the requester,
What is backup withholding? Persons making certain payments
to you must under certain conditions withhold and pay to the
IRS 28% of such payments. This is called “backup withholding.”
Payments that may be subject to backup withholding include
interest, tax-exempt interest, dividends, broker and barter
exchange transactions, rents, royalties, nonemployee pay, and
certain payments from fishing boat operators. Real estate
transactions are not subject to backup withholding.
Payments you receive will be subject to backup
withholding if:
If you are a nonresident alien or a foreign entity not subject to
backup withholding, give the requester the appropriate
completed Form W-8.
Example. Article 20 of the U.S.-China income tax treaty allows
an exemption from tax for scholarship income received by a
Chinese student temporarily present in the United States. Under
U.S. law, this student will become a resident alien for tax
purposes if his or her stay in the United States exceeds 5
calendar years. However, paragraph 2 of the first Protocol to the
U.S.-China treaty (dated April 30, 1984) allows the provisions of
Article 20 to continue to apply even after the Chinese student
becomes a resident alien of the United States. A Chinese
student who qualifies for this exception (under paragraph 2 of
the first protocol) and is relying on this exception to claim an
exemption from tax on his or her scholarship or fellowship
income would attach to Form W-9 a statement that includes the
information described above to support that exemption.
Note. You are requested to check the appropriate box for your
status (individual/sole proprietor, corporation, etc.).
4. The type and amount of income that qualifies for the
exemption from tax.
5. Sufficient facts to justify the exemption from tax under the
terms of the treaty article.
Nonresident alien who becomes a resident alien. Generally,
only a nonresident alien individual may use the terms of a tax
treaty to reduce or eliminate U.S. tax on certain types of income.
However, most tax treaties contain a provision known as a
“saving clause.” Exceptions specified in the saving clause may
permit an exemption from tax to continue for certain types of
income even after the payee has otherwise become a U.S.
resident alien for tax purposes.
If you are a U.S. resident alien who is relying on an exception
contained in the saving clause of a tax treaty to claim an
exemption from U.S. tax on certain types of income, you must
attach a statement to Form W-9 that specifies the following five
items:
1. The treaty country. Generally, this must be the same treaty
under which you claimed exemption from tax as a nonresident
alien.
2. The treaty article addressing the income.
3. The article number (or location) in the tax treaty that
contains the saving clause and its exceptions.
Also see Special rules for partnerships on page 1.
Foreign person. If you are a foreign person, do not use Form
W-9. Instead, use the appropriate Form W-8 (see Publication
515, Withholding of Tax on Nonresident Aliens and Foreign
Entities).
The U.S. grantor or other owner of a grantor trust and not the
trust, and
The U.S. trust (other than a grantor trust) and not the
beneficiaries of the trust.
Limited liability company (LLC). Check the “Limited liability
company” box only and enter the appropriate code for the tax
classification (“D” for disregarded entity, “C” for corporation, “P”
for partnership) in the space provided.
For a single-member LLC (including a foreign LLC with a
domestic owner) that is disregarded as an entity separate from
its owner under Regulations section 301.7701-3, enter the
owner’s name on the “Name” line. Enter the LLC’s name on the
“Business name” line.
For an LLC classified as a partnership or a corporation, enter
the LLC’s name on the “Name” line and any business, trade, or
DBA name on the “Business name” line.
INSTRUCTIONS TO PRINTERS
FORM W-9, PAGE 3 of 4
MARGINS: TOP 13 mm (
1
2"), CENTER SIDES. PRINTS: HEAD to HEAD
PAPER: WHITE WRITING, SUB. 20. INK: BLACK
FLAT SIZE: 216 mm (8
1
2") 3 279 mm (11")
PERFORATE: (NONE)
I.R.S. SPECIFICATIONS
TO BE REMOVED BEFORE PRINTING
DO NOT PRINT — DO NOT PRINT — DO NOT PRINT — DO NOT PRINT
Form W-9 (Rev. 10-2007)
Page 3
13
Part I. Taxpayer Identification
Number (TIN)
Enter your TIN in the appropriate box. If you are a resident
alien and you do not have and are not eligible to get an SSN,
your TIN is your IRS individual taxpayer identification number
(ITIN). Enter it in the social security number box. If you do not
have an ITIN, see How to get a TIN below.
How to get a TIN. If you do not have a TIN, apply for one
immediately. To apply for an SSN, get Form SS-5, Application
for a Social Security Card, from your local Social Security
Administration office or get this form online at www.ssa.gov. You
may also get this form by calling 1-800-772-1213. Use Form
W-7, Application for IRS Individual Taxpayer Identification
Number, to apply for an ITIN, or Form SS-4, Application for
Employer Identification Number, to apply for an EIN. You can
apply for an EIN online by accessing the IRS website at
www.irs.gov/businesses and clicking on Employer Identification
Number (EIN) under Starting a Business. You can get Forms W-7
and SS-4 from the IRS by visiting www.irs.gov or by calling
1-800-TAX-FORM (1-800-829-3676).
If you are asked to complete Form W-9 but do not have a TIN,
write “Applied For” in the space for the TIN, sign and date the
form, and give it to the requester. For interest and dividend
payments, and certain payments made with respect to readily
tradable instruments, generally you will have 60 days to get a
TIN and give it to the requester before you are subject to backup
withholding on payments. The 60-day rule does not apply to
other types of payments. You will be subject to backup
withholding on all such payments until you provide your TIN to
the requester.
If you are a sole proprietor and you have an EIN, you may
enter either your SSN or EIN. However, the IRS prefers that you
use your SSN.
If you are a single-member LLC that is disregarded as an
entity separate from its owner (see Limited liability company
(LLC) on page 2), enter the owner’s SSN (or EIN, if the owner
has one). Do not enter the disregarded entity’s EIN. If the LLC is
classified as a corporation or partnership, enter the entity’s EIN.
Note. See the chart on page 4 for further clarification of name
and TIN combinations.
Note. Entering “Applied For” means that you have already
applied for a TIN or that you intend to apply for one soon.
Caution: A disregarded domestic entity that has a foreign owner
must use the appropriate Form W-8.
9. A futures commission merchant registered with the
Commodity Futures Trading Commission,
10. A real estate investment trust,
11. An entity registered at all times during the tax year under
the Investment Company Act of 1940,
12. A common trust fund operated by a bank under section
584(a),
13. A financial institution,
14. A middleman known in the investment community as a
nominee or custodian, or
15. A trust exempt from tax under section 664 or described in
section 4947.
THEN the payment is exempt
for . . .
IF the payment is for . . .
All exempt payees except
for 9
Interest and dividend payments
Exempt payees 1 through 13.
Also, a person registered under
the Investment Advisers Act of
1940 who regularly acts as a
broker
Broker transactions
Exempt payees 1 through 5
Barter exchange transactions
and patronage dividends
Generally, exempt payees
1 through 7
Payments over $600 required
to be reported and direct
sales over $5,000
See Form 1099-MISC, Miscellaneous Income, and its instructions.
However, the following payments made to a corporation (including gross
proceeds paid to an attorney under section 6045(f), even if the attorney is a
corporation) and reportable on Form 1099-MISC are not exempt from
backup withholding: medical and health care payments, attorneys’ fees, and
payments for services paid by a federal executive agency.
The chart below shows types of payments that may be
exempt from backup withholding. The chart applies to the
exempt payees listed above, 1 through 15.
1
2
7. A foreign central bank of issue,
8. A dealer in securities or commodities required to register in
the United States, the District of Columbia, or a possession of
the United States,
2
The following payees are exempt from backup withholding:
1. An organization exempt from tax under section 501(a), any
IRA, or a custodial account under section 403(b)(7) if the account
satisfies the requirements of section 401(f)(2),
2. The United States or any of its agencies or
instrumentalities,
3. A state, the District of Columbia, a possession of the United
States, or any of their political subdivisions or instrumentalities,
4. A foreign government or any of its political subdivisions,
agencies, or instrumentalities, or
5. An international organization or any of its agencies or
instrumentalities.
Other payees that may be exempt from backup withholding
include:
6. A corporation,
Generally, individuals (including sole proprietors) are not exempt
from backup withholding. Corporations are exempt from backup
withholding for certain payments, such as interest and dividends.
Note. If you are exempt from backup withholding, you should
still complete this form to avoid possible erroneous backup
withholding.
1
1. Interest, dividend, and barter exchange accounts
opened before 1984 and broker accounts considered active
during 1983. You must give your correct TIN, but you do not
have to sign the certification.
2. Interest, dividend, broker, and barter exchange
accounts opened after 1983 and broker accounts considered
inactive during 1983. You must sign the certification or backup
withholding will apply. If you are subject to backup withholding
and you are merely providing your correct TIN to the requester,
you must cross out item 2 in the certification before signing the
form.
Part II. Certification
For a joint account, only the person whose TIN is shown in
Part I should sign (when required). Exempt payees, see Exempt
Payee on page 2.
To establish to the withholding agent that you are a U.S. person,
or resident alien, sign Form W-9. You may be requested to sign
by the withholding agent even if items 1, 4, and 5 below indicate
otherwise.
Signature requirements. Complete the certification as indicated
in 1 through 5 below.
INSTRUCTIONS TO PRINTERS
FORM W-9, PAGE 4 of 4
MARGINS: TOP 13 mm (
1
2"), CENTER SIDES. PRINTS: HEAD to HEAD
PAPER: WHITE WRITING, SUB. 20. INK: BLACK
FLAT SIZE: 216 mm (8
1
2") 3 279 mm (11")
PERFORATE: (NONE)
Form W-9 (Rev. 10-2007)
Page 4
I.R.S. SPECIFICATIONS
TO BE REMOVED BEFORE PRINTING
DO NOT PRINT — DO NOT PRINT — DO NOT PRINT — DO NOT PRINT
Give name and EIN of:
For this type of account:
3. Real estate transactions. You must sign the certification.
You may cross out item 2 of the certification.
A valid trust, estate, or pension trust
6.
Legal entity
4
4. Other payments. You must give your correct TIN, but you
do not have to sign the certification unless you have been
notified that you have previously given an incorrect TIN. “Other
payments” include payments made in the course of the
requester’s trade or business for rents, royalties, goods (other
than bills for merchandise), medical and health care services
(including payments to corporations), payments to a
nonemployee for services, payments to certain fishing boat crew
members and fishermen, and gross proceeds paid to attorneys
(including payments to corporations).
The corporation
Corporate or LLC electing
corporate status on Form 8832
7.
The organization
Association, club, religious,
charitable, educational, or other
tax-exempt organization
8.
5. Mortgage interest paid by you, acquisition or
abandonment of secured property, cancellation of debt,
qualified tuition program payments (under section 529), IRA,
Coverdell ESA, Archer MSA or HSA contributions or
distributions, and pension distributions. You must give your
correct TIN, but you do not have to sign the certification.
The partnership
Partnership or multi-member LLC
9.
The broker or nominee
A broker or registered nominee
10.
The public entity
Account with the Department of
Agriculture in the name of a public
entity (such as a state or local
government, school district, or
prison) that receives agricultural
program payments
11.
Privacy Act Notice
List first and circle the name of the person whose number you furnish. If only one person
on a joint account has an SSN, that person’s number must be furnished.
Circle the minor’s name and furnish the minor’s SSN.
You must show your individual name and you may also enter your business or “DBA”
name on the second name line. You may use either your SSN or EIN (if you have one),
but the IRS encourages you to use your SSN.
List first and circle the name of the trust, estate, or pension trust. (Do not furnish the TIN
of the personal representative or trustee unless the legal entity itself is not designated in
the account title.) Also see Special rules for partnerships on page 1.
Note. If no name is circled when more than one name is listed,
the number will be considered to be that of the first name listed.
Disregarded entity not owned by an
individual
The owner
12.
13
You must provide your TIN whether or not you are required to file a tax return. Payers must generally withhold 28% of taxable interest, dividend, and certain other
payments to a payee who does not give a TIN to a payer. Certain penalties may also apply.
Section 6109 of the Internal Revenue Code requires you to provide your correct TIN to persons who must file information returns with the IRS to report interest,
dividends, and certain other income paid to you, mortgage interest you paid, the acquisition or abandonment of secured property, cancellation of debt, or
contributions you made to an IRA, or Archer MSA or HSA. The IRS uses the numbers for identification purposes and to help verify the accuracy of your tax return.
The IRS may also provide this information to the Department of Justice for civil and criminal litigation, and to cities, states, the District of Columbia, and U.S.
possessions to carry out their tax laws. We may also disclose this information to other countries under a tax treaty, to federal and state agencies to enforce federal
nontax criminal laws, or to federal law enforcement and intelligence agencies to combat terrorism.
1
2
3
4
Secure Your Tax Records from Identity Theft
Identity theft occurs when someone uses your personal
information such as your name, social security number (SSN), or
other identifying information, without your permission, to commit
fraud or other crimes. An identity thief may use your SSN to get
a job or may file a tax return using your SSN to receive a refund.
What Name and Number To Give the Requester
Give name and SSN of:
For this type of account:
The individual
1.
Individual
The actual owner of the account or,
if combined funds, the first
individual on the account
2.
Two or more individuals (joint
account)
The minor
2
3.
Custodian account of a minor
(Uniform Gift to Minors Act)
The grantor-trustee
1
4.
a. The usual revocable savings
trust (grantor is also trustee)
The actual owner
1
b. So-called trust account that is
not a legal or valid trust under
state law
The owner
3
5.
Sole proprietorship or disregarded
entity owned by an individual
Call the IRS at 1-800-829-1040 if you think your identity has
been used inappropriately for tax purposes.
1
To reduce your risk:
Protect your SSN,
Ensure your employer is protecting your SSN, and
Be careful when choosing a tax preparer.
Victims of identity theft who are experiencing economic harm
or a system problem, or are seeking help in resolving tax
problems that have not been resolved through normal channels,
may be eligible for Taxpayer Advocate Service (TAS) assistance.
You can reach TAS by calling the TAS toll-free case intake line
at 1-877-777-4778 or TTY/TDD 1-800-829-4059.
Protect yourself from suspicious emails or phishing
schemes. Phishing is the creation and use of email and
websites designed to mimic legitimate business emails and
websites. The most common act is sending an email to a user
falsely claiming to be an established legitimate enterprise in an
attempt to scam the user into surrendering private information
that will be used for identity theft.
The IRS does not initiate contacts with taxpayers via emails.
Also, the IRS does not request personal detailed information
through email or ask taxpayers for the PIN numbers, passwords,
or similar secret access information for their credit card, bank, or
other financial accounts.
If you receive an unsolicited email claiming to be from the IRS,
forward this message to phishing@irs.gov. You may also report
misuse of the IRS name, logo, or other IRS personal property to
the Treasury Inspector General for Tax Administration at
1-800-366-4484. You can forward suspicious emails to the
Federal Trade Commission at: spam@uce.gov or contact them at
www.consumer.gov/idtheft or 1-877-IDTHEFT(438-4338).
Visit the IRS website at www.irs.gov to learn more about
identity theft and how to reduce your risk.
COLONIAL GENERAL INSURANCE AGENCY, INC.
COMMISSION SCHEDULE
DWELLING FIRE 15% New – 12.5% Renewal
MOBILE HOME 15% New – 12.5% Renewal
MOBILE HOMEOWNERS 15% New – 12.5% Renewal
HOMEOWNERS 15% New – 12.5% Renewal
FARM & RANCH 10%
FLOOD VARIES
PERSONAL UMBRELLA 10%
INLAND MARINE - PERSONAL 10%
INLAND MARINE - COMMERCIAL 10%
COMMERCIAL PROPERTY 10%
COMMERCIAL PROPERTY-PROGRAM 10%
COMMERCIAL PACKAGE 10%
GENERAL LIABILITY 10%
GENERAL LIABILITY-PROGRAM 10%
UMBRELLA - COMMERCIAL 10%
BUSINESS AUTO 10%
GARAGE KEEPERS 10%
EXCESS AUTO VARIES
PROFESSIONAL LIABILITY VARIES
BROKERAGE VARIES
BUSINESS OWNERS (BOP) VARIES
WORKERS COMP VARIES
The above schedule applies to Scottsdale Insurance, Scottsdale Indemnity, and National
Casualty.
Other company commissions may vary.
P.O. Box 14770, Scottsdale, AZ 85267-4770
8475 E. Hartford Dr., Scottsdale, AZ 85255
(480) 991-7889 WATS (800) 848-8860 FAX (480) 948-1394
P.O. Box 571770, Murray, UT 84157-1770
849 W. Levoy Dr., Suite 230, Taylorsville, UT 84123
(801) 290-1144 WATS (800) 594-8900 FAX (801) 290-1160
We would like to thank you for your interest in becoming an appointed broker with
Colonial General Insurance Agency, Inc. Please make sure you have completed the
following before returning your information to us. We cannot proceed with an
appointment until we have received all of the required information.
CHECKLIST:
Completed Producers Brokerage Questionnaire
Completed Contract with signatures
Completed Marketing Information
Attached Affiliate Names & Titles
Attached appropriate License information
Attached copy of Current E&O Declarations Page
FARMERS AGENTS – Please make sure your E&O is Level 3
Attached completed W-9 – Request for Taxpayer ID Number & Certification
Again, thank you for your interest and we look forward to working with you.
If you have any questions, please call Jen PlesKovitch, Broker Licensing at:
480-991-7889 or 1-800-848-8860 ext. 212
Chrome Web Store
It looks like you haven't installed the Fill Chrome Extension Add to Chrome