Fillable Enrollment Request Form for Commercial eBusiness Services (Chubb)

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Enrollment Request Form for Commercial eBusiness Services (Chubb)

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The Enrollment Request Form for Commercial eBusiness Services (Chubb) form is 2 pages long and contains:

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  • 18 check-boxes
  • 21 other fields

Country of origin: UK
File type: PDF

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Enrollment Request Form for
Commercial eBusiness Services
ThefollowingservicesareavailabletosupportChubb’sCommercialLinesagents&brokers.
ToenrollinservicesforPersonalRiskServices,clickhere.
If you need assistance with this form, please contact our eBusiness Help Desk at 1-877-747-5266, option #2 or email
ebusinesshelp@chubb.com.
Please choose from the following services:
CommercialLines‐All
□ PaperFree (Producer Copy) using IVANS eDocs
Select one option:
□ Notiication only
□ Notiication with PDF
□ PaperFree (Policyholder Copy) using IVANS eDocs
Note: Producer Copy Enrollment Required
See Important Notice Paperfree Policyholder Copy
PolicyDownloads
□ Small Commercial – BOP & Umbrella
□ Small Commercial – Workers’ Compensation
AdditionalSolutions
□ Direct Bill Commission Download
□ Claims Download
□ Claims Activities & Notes (Vertafore only)

Agency Name:
Agency Address: ____________________________________________________________________________________________________________________________________________
City: ________________________________________________________________ State: ________________________________________ Zip Code: _____________________________
Office Contact Name: _________________________________________________________ Phone Number: ________________________________________________________
Technical Contact Name: ____________________________________________________ Phone Number: ________________________________________________________
Producer Code(s):
___________________________________________________________________________________________________________________________________________________
Please provide your agency’s IVANS “Y” account information
(If you do not have a ‘Y’ account, please contact your agency management system vendor).
IVANS “Y” Account Number: Batch ID: ________________________________
Machine Address:
1. Select your Agency Management System:
Vertafore Systems: Applied Systems: Other Vendor Systems:
□ Sagitta □ EPIC □ ___________________________________
□ AMS 360 □ TAM (Version #_____)
□ AFW (4-digit participant code: ________) □ Other: _____________________________
□ Other: _____________________________
Ed. June 2020
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Enrollment Request Form for
Commercial eBusiness Services
Policy Delivery Agreement
Important Notice Paperfree Policyholder Copy: This PaperFree Enrollment for the Policyholder’s Copy is limited to
certain lines of coverage (the “Policies”).
The Agency named above hereby elects to receive electronic delivery of Policies for the Agency to deliver to the Policyholder or
its representative. 1 Upon submission of this form, Agency will no longer receive paper copies of the Policyholder’s copy by
regular mail, except as indicated below. Nothing in this Enrollment Agreement amends or alters the rights and obligations of the
Agency or Company as set forth in the Agency Agreement with the Company. Agency’s duties and obligations under this
Enrollment Agreement are an extension of its duties and obligations under its Agency Agreement, and any violation of the terms
and conditions of this Enrollment Agreement will be a violation of the terms and conditions of such Agency Agreement.
If Agency intends to deliver Policies electronically to the Policyholder, Agency must first obtain the written consent of the
Polic
yholder for electronic delivery, which consent must conform to the requirements of all applicable laws and regulations
pertaining to such delivery. At a minimum, such consent must specify the method by which the Policyholder may withdraw
consent and receive a paper copy of future Policies via the U.S. mail, and instructions for changing email address for delivery.
The consent must also specify the format in which the Policies will be delivered, the hardware and software required to view
and retain the Policies, that there is no fee for electing electronic or paper delivery, and acknowledgement from the
Policyholder that by accepting electronic delivery, the Policies will be deemed to have been delivered so long as they are sent to
such email address or via such method of electronic delivery.
Agency understands that it has the option to print and retain paper copies of any electronic records generated and to obtain
paper copies of any electronic records generated via this Broker Management Mailbox site concerning its client’s coverage(s).
Agency must immediately notify the Company in writing of any print inconsistencies with the electronic records so that paper
copies of such records can be delivered to its Policyholder, or if the Policyholder wants to withdraw consent to PaperFree
delivery. Such notice must include the Policyholder’s name and affected Policy numbers. Upon occurrence of any of the
foregoing, Agency will use its own printing facilities or request Company to print and mail a copy of the Policies for Agency to
deliver to the Policyholder. Agency must maintain records evidencing each Policyholder’s consent to electronic delivery of
Policies, which records must be available for inspection by Company upon reasonable notice.
Agency also understands that it must immediately notify the Company in writing in the event its contact information
or
Policyholder’s information changes, any error is detected or its status as Broker of Record for any Policyholder
ceases.
Agency understands that to access and conduct transactions relating to its
Policyholder’s coverage via this Broker Management
Mailbox site, Agency must have access to a computer which is capable of supporting Internet access, and a compatible browser
application. Agency agrees to the use of electronic signatures and electronic records for current and future transactions
conducted through the Broker Management Mailbox effective on the date this form is submitted to Company.
By checking the “I Agree” box, you acknowledge that you agree to the electronic delivery of the policyholder’s policy to
agen
cy on behalf of the policyholder in accordance with the “important notice paperfree policyholder copy” above, and to
be legally bound, with respect to this agreement, as if you had signed this agreement with a hand written signature. You
may print or retain a copy of this agreement for your records.
I agree
Effective Date:
Name: Title:
1
In some cases, there may be documents that we cannot deliver electronically due to legal and/or technological constraints. These documents will be delivered to you via
the United State Postal Service (USPS) to your postal address on file.
Ed. 5/2020
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Enrollment Request Form for Commercial eBusiness Services (Chubb)

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Completed 10 June 2021

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