Fillable Insurance Subscription Agreement Form Instructions Page 1 (IntelliCorp)

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Insurance Subscription Agreement Form Instructions Page 1 (IntelliCorp)

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Insurance Subscription Agreement Form Instructions
Page 1
Page 2
Pages 3 & 4 do not require input, but must be submitted along with pages 1, 2, and 5
Page 5
Legal name required; trade
names can be listed as DBA
Mailing and physical
address required. If they
are the same, indicate such.
If there are multiple
locations enter the primary
or HQ location
Provide company website.
If you do not have one,
enter N/A
First and last name of
contact must be entered
Appropriate box must be
checked. Indicate type of
business and enter
applicable code
Use primary phone
and fax numbers; do
not use direct lines.
If you do not have a
fax, enter N/A
Federal Tax ID
Number; not state
Location: one
selection must be
made
Email address is required.
If you do not have an email,
enter N/A
Appropriate boxes
must be checked
[check all that apply.
Indicate the reason
why your organization
is ordering searches
Proof of Valid
Business or
“document type”
must be indicated
Company name must be
the same as what was
entered as Legal Name on
Page 1
State reflected must be
the State of incorporation
City and state
reflected in Physical
Address from Page 1
must be entered
here
Signature, Date,
Name, Title, and
Email must be
entered legibly. The
document must be
signed by an
individual who has
authority to do so
Created 07-01-15
Version ICI2015.1
Please provide all requested information below (PLEASE TYPE OR PRINT).
1. The agreement must be signed by an owner, officer, director, partner, principal, or other person legally authorized to bind the company.
2. Make copies for your files, mail originals to IntelliCorp, 3000 Auburn Drive, Suite 410; Beachwood, OH 44122 or you may fax to 216.450.5249 or email to
MVRCompliance@Intellicorp.net
ONE of the following MUST accompany this agreement: A CURRENT AND VALID BUSINESS LICENSE, OR A COPY OF ONE OF THE FOLLOWING dated
within the last 24 months : CURRENT STATE SALES AND USE TAX CERTIFICATE, OFFICIAL FEDERAL TAX DOCUMENTS - 940, 941, OR FEDERAL TAX
RETURN (W-9 is not acceptable)
Decline Automatic Archive Search Decline Automatic State Database Search - MO only Decline Automatic State Database Search - OH only
COMPANY INFORMATION
LEGAL NAME: _______________________________________________________________________
DBA: ________________________________________________________________________
WEBSITE: ________________________________________________________________________
TYPE OF BUSINESS:
Insurance Agency: Type(s) PL CL Life
Insurance Company: Type(s) PL CL Life AM Best # __________/ NAIC Code __________
Other: ____________________________________________________________________________
FED TAX ID: ___________________________
BUSINESS DOCUMENT ATTACHED::
(check one)
940, 941 or Federal Tax Return
Business License
State Sales and Use Tax Certificate
Other Business Document
REASON FOR ORDERING SERVICES (check all that apply):
My business orders reports for Underwriting purposes for these insurance line(s): PL CL Life Insurance
My business orders services for another reason (please explain): ____________________________________________
MAILING ADDRESS:
________________________________________________________________
ADDRESS 1
________________________________________________________________
ADDRESS 2
________________________________________________________________
CITY STATE ZIP
PHYSICAL ADDRESS
_________________________________________________________________
ADDRESS 1
_________________________________________________________________
ADDRESS 2
_________________________________________________________________
CITY STATE ZIP
LOCATIONS (attach list if needed): _____________________________________________________________________________________________________
BUSINESS LOCATION: COMMERCIAL (office or building) RESIDENTIAL (home-based or zoned residential)
CONTACT INFORMATION
PHONE NUMBER: ______________________/__________________________
BUSINESS ALTERNATE
FAX NUMBER: ______________________/__________________________
BUSINESS ALTERNATE
PRIMARY CONTACT NAME: __________________________________________________________________________________________________
PRIMARY CONTACT EMAIL: __________________________________________________________________________________________________
iiX USE ONLY
DATE
SOURCE
Intellicorp
SALES PERSON
TGC
ACCOUNT ID
PASSWORD
ACCT TYPE
INS
DETAIL PG
ACCESS FEE
RATE CLASS
N/A
SPONSOR ACCT TO BILL
998559
NAME
IntelliCorp
DIRECT BILL CODES
VERIFIED Date: Initials:
SET UP FEE
TERMS OF AGREEMENT MVRCompliance@Intellicorp.net
On-site visit Initials:
iiX
Insurance Subscription Agreement
Page 2 of 5
Created 07-01-15
Version ICI2015.1
Subscription Agreement – Terms and Conditions
This subscription agreement (“the Agreement”) is entered into as of the date of execution below (the “Effective Date”), by and between ISO Claims
Services, Inc., a Delaware corporation, through its Insurance Information Exchange unit (“iiX”) with offices at 1716 Briarcrest, Suite 200 Bryan, TX
77802, and ________________________________________________________________________________________________, (Customer Name)
a ______________ (State) corporation/other entity with offices at ________________________________________________ (City, State).
1. SERVICES AND RATES. Certain reports, records, products, and/or services (collectively, “Information Services”) that may include Motor Vehicle
Reports (“MVRs”), Undisclosed Driver Information (“UDI”), Undisclosed Driver and VIN report (“UDV”), A-PLUS (a product of ISO Services, Inc.), and
Scored Credit (a product of TransUnion), will be provided to Customer under the terms specified in this Agreement. State-set record fees are subject to
change at any time.
2. SOLE USE AND OUTSOURCING. Customer warrants and agrees that any requests made for Information Services are for the sole and internal
use of Customer and are to be used only as a factor in establishing a consumer's eligibility for new or continued insurance purposes, unless otherwise
restricted further by Specific State Forms (as defined below). Customer may deliver the Information Services to Customer’s employees and authorized
users solely as needed to perform functions consistent with this Agreement’s purpose. All such individuals shall be subject to this Agreement’s terms
and conditions and all applicable laws and regulations. Except as provided in Section 2.1, no one acting by or through Customer may sell, transfer,
distribute, publish, disclose, display or otherwise make the Information Services available, in whole or in part, or any of the information in them, to any
other person or entity, without the express written consent of iiX.
2.1 Use of Outsourcing Customer warrants and agrees that to the extent it has entered into or may enter into an arrangement with a third party
to provide services on Customer’s behalf (“Outsourcer”) to process Information Services, the arrangement shall be consistent with this Agreement
and solely for the purpose and benefit of Customer. The Information Services may be provided to Outsourcer solely to enable it to assist
Customer under this Agreement, provided that Customer, (1) if required by applicable federal or state regulatory frameworks, discloses to any
affected consumer(s) that his/her information might be subject to outsourcing, including possible offshore access, and obtains the consumer’s
permission for such access, and (2) requires such Outsourcer, in writing, to confirm that it will (i) use the Information Services solely on behalf of
or for the benefit of Customer, (ii) abide by all Agreement terms and conditions regarding nondisclosure and use of the Information Services, and
(iii)
be s
ubject to any applicable laws and regulations, including but not limited to those governing privacy and the use of Personal Information
(defined below). A copy of the agreement between Customer and Outsourcer will be supplied to iiX upon iiX’s request.
2.2 Prohibitions Customer acknowledges that certain state and/or iiX data providers may prohibit access to their information by offshore users.
Customer agrees not to permit offshore access by any of its employees, authorized users, or Outsourcer in violation of any prohibition against
offshore access to records, and agrees to be responsible for the use of the Information Services by its employees, authorized users, or
Outsourcer in violation of this section.
Failure of Customer to comply in all respects with the requirements of this Section 2 is a material breach of this Agreement. In such event, iiX may
immediately terminate this Agreement and the delivery of any Information Services to Customer without notice or delay.
3. RESTRICTIONS.
3.1. Confidentiality Customer acknowledges that in connection with this Agreement, it may receive Personal Information (defined below) and
nonpublic Personal Information from state agencies and service bureaus. Personal Information is information that identifies an individual and
includes, but is not limited to: (a) first and last name or first initial and last name; (b) a home or other physical address, which includes at least street
name and name of city or town; (c) an email address; (d) a telephone number; (e) a Social Security number; (f) credit and/or debit card information,
including credit and/or debit card number with expiration date; (g) date of birth; (h) a driver’s license number; or (i) any other information from or
about an individual consumer that is combined with (a) through (h) above. Consistent with Section 2 of this Agreement, Customer agrees to treat
as confidential all Personal Information received from iiX and to disclose consumer information only to those authorized who have a need to know
such information to accomplish their duties. Customer and its authorized users shall not use Personal Information for any purpose except the
purpose permitted by this Agreement.
3.2. Compliance with Laws Customer certifies that it shall order, receive, disseminate and otherwise use the Information Services in compliance
with all applicable federal, state and local statutes, rules, codes and regulations, including but not limited to the Fair Credit Reporting Act (“FCRA”),
the Driver's Privacy Protection Act (“DPPA”), 18 U.S.C. §2721 et seq., the Gramm-Leach-Bliley Act (“GLB”) and their state equivalents, including
any changes, supplements or amendments to such statutes, rules, codes and regulations (collectively, “The Laws”). Customer understands that
violators of the FCRA, the DPPA, and other federal and state laws governing protection of Personal Information are potentially subject to civil
actions and penalties, including fines. Customer shall be responsible for understanding and for staying current with all of The Laws. Customer
further represents and warrants that it shall ensure the security and confidentiality of Personal Information in compliance with The Laws. iiX
acknowledges that it has appropriate administrative, technical and physical safeguards, including data security safeguards, in place to protect
Personal Information consistent with federal and state requirements applicable to it.
3.2.1 Notification in Event of Breach or Misuse of Information. Customer will immediately notify iiX of any inadvertent or unauthorized
release of the Information Services obtained under this Agreement or other security breach of Personal Information contained in Information
Page 3 of 5
Created 07-01-15
Version ICI2015.1
Services when the Customer knows of such unauthorized or inadvertent release. Customer agrees to notify all affected consumers in writing
that their Personal Information has been potentially compromised in the event of the Customer’s or its authorized users’, including any
Outsourcer’s, inadvertent or unauthorized release, misuse, or other security breach of Personal Information contained in the Information
Services supplied to Customer. Customer shall retain documentation of such notification and provide it to iiX and governmental
representatives immediately upon request.
3.3. Specific State Forms Customer shall be responsible for understanding and for staying current with all specific state forms, certificates of use
or other documents or agreements, including any changes, supplements or amendments to them imposed by the states (collectively, “Specific State
Forms”) from or under which it will order Information Services. Customer certifies that it has filed all applicable Specific State Forms required by
individual states. If Customer receives Information Services from a State requiring a state form, Customer agrees that it shall sign a copy of the
appropriate state agreements and return them to iiX.
3.4. Publications Customer agrees that all solicitations, advertising copy and other communications used in connection with Information Services
shall be devoid of any reference to any selection criteria or presumed knowledge concerning the intended recipient of such solicitation, or the
source of the recipient's name and address. Customer further warrants that telephone numbers submitted to iiX for reverse telephone append
matching services will not be randomly generated or obtained by an automatic number identification system, except where a prior business
relationship exists between Customer and the owner of such telephone number.
3.5. Archiving Customer and any of its authorized user(s), including any Outsourcer, shall not use Information Services or data derived from them,
including any MVR data, supplied by or through iiX to directly or indirectly compile, store, or maintain the Information Services or derivative data
(independent of or commingled with other databases) to develop its own source or database of such services or data.
3.6. Other Restrictions iiX may from time to time impose additional restrictions, procedures or processes upon the use and/or delivery of the
Information Services that it believes to be prudent to ensure compliance with The Laws, the Specific State Forms and/or the security, privacy or
confidentiality of the Information Services.
3.7. Interpretation In the event that Customer and iiX disagree with the intent, effect, necessity to comply with or the interpretation and/or
compliance requirement of any of The Laws or Specific State Forms, Customer shall conform to iiX’s interpretation.
3.8. Use of the Internet Customer and any of its authorized user(s), including any Outsourcer, will not disseminate any unsecured or unencrypted
Information Services over the Internet. Internet dissemination includes e-mail, World Wide Web access, FTP and all other mechanisms where data
is transmitted across the Internet. This shall not prohibit Customer from transmitting such information over a secure network to Customer’s
authorized users with a legitimate need to receive the information, provided that such actions comply with The Laws as well as any other state and
federal statutes and regulations governing the confidentiality, security and transmission of the Information Services.
F
ailure of customer to fully comply with the requirements of all of Section 3 shall be a material breach of this Agreement and shall permit iiX to
immediately terminate this Agreement and the delivery of any Information Services to Customer without notice or delay.
4. WARRANTY AND INDEMNIFICATION. Customer represents and warrants that any data, content or other materials provided by Customer to iiX are
in compliance with all applicable laws and will not, when used by iiX, defame any person or infringe the trademarks, service marks, copyrights or other
intellectual property rights of any third party. Customer agrees to indemnify and hold harmless iiX, its affiliated companies and their officers, directors,
employees and shareholders from any and all damages, costs, judgments and expenses (including reasonable attorney’s fees) as well as any and all
fines, interest, penalties or any other liabilities: (i) incurred by iiX, (ii) imposed by local, state or federal authorities or (iii) claimed by any third party whic
h
r
esult from or arise out of Customer’s failure to fully comply with the provisions of Sections 2, 3 and 4 or the use by Customer or its authorized users,
including any Outsourcer, of the Information Services provided under this Agreement.
5. TERMINATION. Customer may terminate this Agreement at any time with thirty (30) days prior written notice to iiX. Customer agrees, however, to
pay for all requests received by iiX prior to termination. Except as provided in Sections 2 and 3, iiX may terminate this Agreement or amend this service
by providing ten (10) days prior notice to Customer. iiX may amend this Agreement or terminate without notice if the availability of an Informati
on
S
ervice to iiX changes for any reason during the term of this Agreement.
6. DISCLAIMERS.
C
USTOMER UNDERSTANDS AND AGREES THAT THE FOLLOWING LIMITATIONS ARE AN ESSENTIAL PART OF THE CONSIDERATION TO iiX
FOR ENTERING INTO THIS AGREEMENT. THE LIMITATIONS ARE SPECIFICALLY DESIGNED AND AGREED TO BY THE PARTIES TO
ALLOCATE AND LIMIT RISKS BETWEEN THE PARTIES IN LIGHT OF THE PRICES CHARGED AND THE OTHER BUSINESS TERMS OF THIS
AGREEMENT.
C
ERTAIN OF THE INFORMATION SERVICES PROVIDED UNDER THIS AGREEMENT ARE FROM INFORMATION OR SERVICES SUPPLIED BY
VARIOUS STATE AGENCIES, SERVICE PROVIDERS, AND OTHER SERVICE BUREAUS (COLLECTIVELY, “DATA PROVIDERS”). THE
INFORMATION SERVICES ARE PROVIDED "AS IS" AND NEITHER iiX NOR ITS DATA PROVIDERS IN ANY WAY WARRANT OR ASSUME ANY
Page 4 of 5
Created 07-01-15
Version ICI2015.1
LIABILITY FOR THE ACCURACY, TIMELINESS, MERCHANTABILITY, FITNESS FOR PARTICULAR PURPOSE AND/OR COMPLETENESS OF ANY
INFORMATION SERVICE PROVIDED UNDER THIS AGREEMENT.
AT
THE DISCRETION OF THE CUSTOMER, WHERE PERMITTED, MOTOR VEHICLE REPORTS MAY BE SUPPLIED FROM DATABASE OR
HISTORY FILES. THESE DATABASE REPORTS MAY NOT CONTAIN THE SAME DATA AS A CURRENT STATE REPORT. THE REPORT WILL BE
NOTED AS A DATABASE REPORT AND WILL SHOW THE ORIGINAL REPORT DATE.
N
EITHER iiX NOR ITS DATA PROVIDERS ASSUME RESPONSIBILITY FOR CHARGES INCURRED, LOST REVENUE, OR INCIDENTAL, SPECIAL,
PUNITIVE OR CONSEQUENTIAL DAMAGES OF ANY KIND OR NATURE DUE TO ANY CAUSE WHATSOEVER, INCLUDING BUT NOT LIMITATED
TO, ERRORS IN CUSTOMER INPUT, DUPLICATE REQUESTS, ERRORS IN TRANSMISSION, PROGRAM OR EQUIPMENT FAILURES,
COMMUNICATION PROBLEMS, PROCESS DELAYS, OR SCHEDULE CHANGES. IN NO EVENT SHALL iiX'S OR THE APPLICABLE DATA
PROVIDER’S LIABILITY EXCEED THE CHARGES ACTUALLY PAID TO iiX BY CUSTOMER IN THE THREE (3) MONTHS IMMEDIATELY
PRECEDING ANY SUCH CLAIM.
7. CREDENTIALING. Credentialing is the process for verifying that entities are legitimate and their purpose for the use of the Personal Information is
authorized.
7.1. Pre-Service Review iiX will verify Customer’s identity and permissible purpose to request Information Services through a certification or pre-
service review. This review may include but not be limited to a verification of the type of business, confirmation that the stated permissible purpose
for obtaining the product or service is compatible with the type of business conducted, conducting a physical inspection of the premises to assure
that it is a legitimate business facility, verification of specified credentials, and verification of business phone and address records and web pages
through the use of recognized third parties. Customer agrees to cooperate fully with any certification process or pre-service review prior to iiX
permitting access to Information Services.
7.2. Credential Monitoring Customer further agrees to cooperate fully with continued monitoring of Customer credentials. Monitoring includes the
recertification of credentials and update of agreement. iiX reserves the right to make such requests as it deems necessary. Failure to comply
could result in restriction or termination of access to the Information Services.
8. AUDIT. Upon receipt of iiX audit requests, Customer agrees to respond within the time period specified in the audit notice or request for information.
Customer shall provide all documentation as requested. This information shall be made available to iiX for review and copying upon iiX’s request or to
any governmental authority upon request. Access privileges to Information Services will be suspended upon failure to comply with such requests.
Customer agrees that it will not obstruct a governmental authority’s audit at the Customer’s site in connection with the ordering or use of Information
Services.
9. RETENTION OF INFORMATION.
9.1. Retention of Information Services Materials and Data The Customer and its authorized users, including any Outsourcer, shall promptly and
adequately destroy data and materials from the Information Services (including MVRs) in its/their possession when they are no longer required for
the purpose as stated in this Agreement.
9.2. Retention of Requestor Information Customer must maintain records identifying each person or entity that receives the Personal Information
and the permitted purpose for which the Personal Information will be used. These records must be retained for a period of (5) five years and shall
include, but not be limited to, the: request date, requested individual, requestor, permissible purpose for each Information Services and, as
appropriate, signed disclosure/authorization forms from affected consumer(s).
9.3. Destruction of Information All materials and data containing Personal Information that have been obtained from or through iiX must be
properly disposed of by taking reasonable measures to protect against unauthorized access to or use of the information in connection with its
disposal. This would include, but not be limited to, implementing and monitoring compliance with policies and procedures that require the burning,
pulverizing, erasing or shredding of papers or records containing Personal Information so that the information cannot practicably be read or
reconstructed. Electronic files or media containing Personal Information must be destroyed or erased so that the information cannot be read or
reconstructed.
10. INDEPENDENTLY CONTRACTING PARTIES. The relationship of the parties shall be that of independently contracting parties. Nothing in this
Agreement shall be construed to create any partnership, joint venture, agency or other similar relationship. Neither party shall have the right or authority
to create, assume or imply any obligation or responsibility on behalf or in the name of the other party or bind the other party in any manner.
11. NOTICES. Notices sent to either party shall be effective when delivered in person, one day after being sent by overnight courier, or five (5) days
after being sent by certified mail postage prepaid to the address set forth above for such party, or to such other address as the party, to which such
notice is being sent, may from time to time have specified in an earlier notice to the party sending such notice. In addition, notices to Customer sent by
e-mail to Customer’s e-mail address identified in this Agreement shall be effective when sent. Customer shall notify iiX of any changes in Customer’s e-
mail address.
12. CHOICE OF LAW. This Agreement shall be governed by and construed in accordance with the substantive laws of the State of New York. The
state or federal courts of the State of New York shall have exclusive jurisdiction over any claims arising out of or in any way related to this Agreement.
Page 5 of 5
Created 07-01-15
Version ICI2015.1
13. FORCE MAJEURE. Except for payment obligation, neither party shall be liable for any failure or delay in performance directly or indirectly caused by
acts or omissions beyond the reasonable control of the party required to perform. In the event that a party is asserting force majeure as its reason for
failing to timely perform, such party shall immediately notify the other party of the situation and shall use every reasonable effort to remove the conditi
on
of
force majeure and begin performance.
14. MISCELLANEOUS. This document and any amendments as well as the Exhibits, if any, referenced and incorporated in it and all documents
referred to in those Exhibits, if any, constitute the entire agreement between the parties with respect to its subject matter and supersede all other
communications, whether written or oral. Except as set forth in Section 3.6, this Agreement may be modified or amended only in a writing signed by both
parties. Waiver of any provision in one instance shall not preclude its enforcement in the future. Headings are for reference purposes only and have no
substantive effect.
15. SEVERABILITY. The provisions of this Agreement shall be severable, and if any provision shall be held or declared to be illegal, invalid or
unenforceable, such illegality, invalidity, or unenforceability shall not affect any other provision, and the remainder of this Agreement, disregarding such
invalid portion, shall continue in full force and effect as though such invalid provision had not been contained in it.
16. SURVIVAL. The provisions of Sections 2, 3, 4, 5, 6, 8, 9, 10, 11, 13, 14, and 15 of this Agreement shall survive the expiration, cancellation,
termination or non-renewal of this Agreement.
17. COUNTERPARTS. This agreement may be executed in two or more counterparts, each of which shall take effect as an original and all of which
together shall evidence one agreement.
18. ASSIGNMENT. Customer shall not assign or subcontract this Agreement without the prior written permission of iiX and any such assignment or
delegation, either full or partial, to any third party is void and of no effect. A merger, consolidation, reorganization or other change of control shall be
considered an assignment for the purposes of this Agreement. All terms and provisions of this Agreement shall be binding upon and inure to the benefit
of the parties and their respective permitted transferees, successors and assigns.
T
HE UNDERSIGNED CERTIFIES THAT HE/SHE HAS READ, UNDERSTANDS, AND AGREES TO THE TERMS AND CONDITIONS DESCRIBED IN
THIS SUBSCRIPTION AGREEMENT, AND ANY APPLICABLE STATE AGREEMENTS. THE UNDERSIGNED FURTHER AFFIRMS THAT THE
STATEMENTS MADE IN THIS AGREEMENT ARE TRUE AND CORRECT, AND THAT HE/SHE HAS DIRECT KNOWLEDGE OF THE FACTS
CERTIFIED IN THIS AGREEMENT AND AUTHORITY TO MAKE THE ABOVE REPRESENTATIONS AND TO ENTER INTO THIS AGREEMENT AS
A PERSON LEGALLY AUTHORIZED TO BIND THE COMPANY (OWNER, OFFICER, DIRECTOR, PARTNER, PRINCIPAL, OR OTHER
REPRESENTATIVE WHO IS LEGALLY AUTHORIZED TO BIND THE BUSINESS).
S
IGNATURE:____________________________________________________________________DATE:______________________
Owner or Officer or Legally Authorized Representative
N
AME (Printed):___________________________________________________TITLE:_____________________________________
E-MAIL ADDRESS OF SIGNEE:_________________________________________________________________________________
1716 Briarcrest, Suite 200.
Bryan, Texas 77802
DIRECT UNDERWRITING STATEMENT
Company Name: _________________________________________________
Company Address: _______________________________________________
________________________________________
________________________________________
We understand that the records or reports obtained through iiX will be used only by our aforementioned
insurance agency or company listed above, for underwriting purposes.
The r
ecords or reports will not be passed on to any prospective employers or third parties and will remain
in the possession of our insurance agency/company or, as appropriate, insurance carriers that our
company services.
We un
derstand that the reason iiX is requesting this information is because the website or other
information suggests that our insurance agency operates or is affiliated with more than one business and
the records or reports could be viewed/used by another party.
_______________________________________
Signature
_______________________________________
Title
_______________________________________
Date
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Insurance Subscription Agreement Form Instructions Page 1 (IntelliCorp)

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Completed 29 July 2020

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