1
Please send with Agency License, E&O Dec, W-9 Tax Form & Producer Agreement to: 916.780.7181
or Email to : receptionist@abraminterstate.com
Abram Interstate Insurance Services, Inc.
2211 Plaza Drive, Suite 100, Rocklin, CA 95765
Phone (916) 780-7000 or (800) 955-4465
Fax (916)780-7181 www.AbramInterstate.com
License # 0D08440
Agency Profile Questionnaire
Your cooperation is appreciated in completing the following questionnaire.
Any and all information, verbal or written, will be held by us in the strictest confidence.
Agency Name: __________________________________________________________________________
Corporation ____ Partnership ____ Individual ____ Agency License #________________
Names of Principals & Titles: _______________________________________________________________
_______________________________________________________________________________________
Street Address: __________________________________________________________________________
Mailing Address (if different): _______________________________________________________________
Social Security # ___________________ Tax ID # __________________ Year Agency Formed __________
Phone: _________________ Fax: __________________ Principal E-mail: ____________________________
General Agents or Wholesalers Contracted with: Direct Contract Companies:
1) ______________________________________
2) ______________________________________
3) ______________________________________
1) ____________________________________
2) ____________________________________
3) ____________________________________
FSC # ____________________________ ADR # ________________________________________
Agency Management System: _________________ Rating Systems used: __________________________
Premium Volume: Personal Lines __________________ Commercial Lines _________________________
How did you hear about Abram Interstate: _____________________________________________________
Bank References:
Name: __________________________________ Address: _______________________________________
Phone: ______________________________ Account Number: ___________________________________
Do you maintain E & O Insurance for Property and Casualty Insurance Sales: Y / N Effective Date: ________
Company Name: ____________________________________ Policy Number:__________________________
What other coverages, products, and programs do you have a need for: ___________________________
_____________________________________________________________
The undersigned hereby declares that the answers with respect to the foregoing questions are true, complete and
accurate with no misrepresentation, omission or any other concealment of fact. Producer warrants that it will act in
accordance with applicable State and Federal Privacy Laws. Producer further expressly gives permission to General Agent
to provide various marketing information and materials from time to time, including facsimiles and e-mails sent to
producer’s place of business. If you do not wish to receive these materials, you agree to notify General Agent in writing
at the location listed at the bottom of this agreement.*
Date: ____________ Completed & Signed by: _____________________________Title: __________________
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Please send with Agency License, E&O Dec, W-9 Tax Form & Producer Agreement to: 916.780.7181
or Email to : receptionist@abraminterstate.com
Additional Contact Information:
Agency Name: __________________________________________________________________________
Personal Lines:
Name_________________________________________ Email______________________________________
Commercial Lines:
Name_________________________________________ Email______________________________________
Agri-Business:
Name_________________________________________ Email______________________________________
Other:
Name_________________________________________ Email______________________________________
*________________________________________________________
Abram Interstate Insurance Services, Inc.
2211 Plaza Drive, Suite 100, Rocklin, CA 95765
Phone (916) 780-7000 or (800) 955-4465
Fax (916) 780-7181 www.AbramInterstate.com
License # 0D08440
Producers Agreement
This agreement made effective, , 20 _, by and between Abram Interstate Insurance
Services, Inc. of California, hereinafter referred to as General Agent and
(licensed insurance agent (s) and or broker (s) of,
in the State of hereinafter referred to as Producer.
Witness
(1) Producer desires to place a certain insurance business with the General Agent and General Agent desires to accept
certain insurance business from the said Producer.
(2) Producer shall be liable for the full amount of premium, fees, state taxes, less commission, including additional
and/or adjustable premiums developed under audits or applicable rating plans on every insurance contract placed
by the Producer through the General Agent. Producer shall remit the balance of the premium, less any fees, applicable
taxes and commission, to General Agent, no more than ten days after the effective date of such contract, audit, rating
plan or other adjustment.
(3) No policy may be returned to the General Agent for flat cancellation unless it is returned and received prior to the
inception date of the contract. Earned premium and policy fees shall be computed and charged on every policy canceled
after inception in accordance with the cancellation provisions of such policy.
(4) In consideration of commission allowed Producer on all premiums and additional premiums, Producer agrees to pay
General Agent the commission on all returned premiums the same rate at which such commissions were earned & paid.
(5) Producer acknowledges it is not the agent, and has no authority to bind General Agent or any of its principals or
insurers. Producer warrants it is the agent of the insured and acknowledges General agent bears no agency or fiduciary
responsibility to the insured.
(6) Producer agrees to maintain an Errors and Omissions policy in force during the duration of this contract and/or while
placing business with the General Agent.
(7) No Producer has the authority to assign or adjust any claims on behalf of the General Agent or its companies. All claims
are to be reported to the General Agent or Company for assignment and handling within 24 (twenty-four) hours in
conjunction with California Unfair Claims Settlement Practices Regulations.
(8) Commissions paid to the Producer by the General Agent are subject to change without prior notice although
Producer will receive such changes in writing from the General Agent.
(9) The furnishings of promotional materials, including, but not limited to: kits, applications, rate schedules,
specimen policies, brochures, advertising or any other material by General Agent does not create or imply an agency
relationship or binding authority between General Agent and Producer.
This agreement shall apply to all future insurance contracts, which may be placed by the General Agent on the behalf of
the Producer.
This agreement may be canceled at any time by written notice of either party to the other, but said cancellations shall
not alter in any way the continued application of this agreement to the insurance contracts affected prior to the date of such
cancellations. Use and control of expirations shall be left in the Producers undisputed possession, provided the Producer shall
promptly account for and pay all premiums and return commissions for which he may be liable: if the Producer fails to do
so, the records, and use and control of expirations shall be vested exclusively with the General Agent.
Producer further expressly gives permission to General Agent to provide various marketing information and materials
from time to time, including facsimiles and e-mails sent to producer’s place of business. If you do not wish to receive these
materials, you agree to notify General Agent in writing at the location listed at the bottom of this agreement.*
This agreement constitutes the full and complete contract between the General Agent and the Producer. Neither party
has relied upon any oral representation not included herein. Any Amendment to this agreement shall be made only with the
consent of both parties and attached hereon through addendum.
AGENT/ BROKER: Abram Interstate Insurance Services, Inc.
Signature Date Signature Date
Created on
5/8/07
Agency Authorization Agreement
Fax to 916-780-7181 or email to aiis@abraminterstate.com
AGENCY INFORMATION:
Trust Account (Premium Sweep) BANK INFO:
Financial Institution:________________________________________________
Bank Routing # ___________________________________________________
Bank Account # ___________________________________________________
Operating Account (Commission) BANK INFO:
Financial Institution:________________________________________________
Bank Routing # ___________________________________________________
Bank Account # ___________________________________________________
I, the undersigned, hereby authorize Abram Interstate Insurance Services, Inc. to deposit to and draft from
Producer’s named depository(s) variable amounts indicated by the payment and new business
transmittal received by Producer from the Company with the quote, as well as the commission amounts
indicated on my commission statements. Any disputes regarding the amount drafted from the Producer’s
account shall be resolved as soon as practical. A $25.00 fee will be charged for all NSF transactions. This
agreement shall remain in full force and effect until such time as either the Producer or Company gives written
notice of the intent to terminate. Termination of this agreement does not release any outstanding obligations
of the Producer to the Company.
Authorized Signature: _______________________________
Printed Name: _____________________________________ Date Signed: ______________________
** ALL PAYMENTS & COMMISSIONS WILL BE WITHDRAWN AND/OR DEPOSITED FROM YOUR
BANK ACCOUNT VIA ELECTRONIC FUNDS TRANSFER **
For questions, please call our Accounting Department at 916.780.7000.
Attach copies of VOIDED Trust and Operating Checks
Agency Name:_____________________________________________ Office# ______________________
Address:__________________________________________________ Contact#_____________________
City:_____________________________________________________ Fax#_________________________
State:________ Zip:___________________Email:____________________________________________