Printed Name of Agency Principal
The undersig
ned hereby declares that the answers given with respect to the foregoing questions are true, complete, and
accurate with no misrepresentations, omissions, or any other concealment of fact.
__________________________________________________
Signature of Agency Principal Date
Printed Name of Agency Principal
Agency Principal Phone Number Agency Principal Email Address
DIRECT COMMISSION DEPOSIT INFORMATION
1. Name on Account:
2. Bank Name:
3. Address:
4. Account Type: Checking Savings
5. Routing Number: Account Number:
6. If you wish to decline direct deposit and receive payment by check, check this box
Agency Bill Questionnaire (Optional)
To be considered for Agency Bill privileges with Philadelphia Insurance Companies (‘PHLY’), I understand and agree with
the following:
1.
My Agency may not bill the Insured any premium amount charged by PHLY other than that
quoted and bound with PHLY. If no, please explain:
2.
My Agency may not bill any non-premium amount to an Insured of PHLY unless such amount
is permitted by law, is properly disclosed to the Insured in accordance with the provisions of
each applicable law or regulation, and is
set forth separately from premium charged by PHLY
on any Agency invoice to the Insured. If no, please explain:
3.
My Agency does not commingle premium funds with non-premium funds.
If no, please explain:
4.
My Agency shall maintain a system of internal controls and record keeping mechanisms for
the safekeeping and full accounting of all premium billings, collections, and policyholder
records relating to policies of insurance issued by the PHLY.
The undersigned hereby declares that the answers given with respect to the foregoing questions are true, complete, and
accurate with no misrepresentations, omissions, or any other concealment of fact.
____________________________________________________________
Signature of Agency Principal Date
Yes No
Yes No
Yes No
Yes No
Agency Principal/Producer Profile
