Application Form | Versatile Insurance Services LLC

Applicant Information

First Name*

Middle Name

Last Name*

Address*

Street Address Address Line 2 City State ZIP Code

Social Security Number*

Drivers License Number

Date of Birth*

Gender*

Male
Female

Home Phone Number

Cell Phone Number

Home Fax Number

Email*

Please only enter a single email address.

Working with GA?

Please enter the General Agency Name.

Were you referred by another agent?

Please enter the name of the agent.

National Producer Number

Don't know your NPN? Click here to search.

Agency Information

Business Name

Business Phone Number

Business Fax Number

Email

Please only enter a single email address.

Tax ID #

Business Tax Class

Address

Business Address Business City Business State Business Zip

Business Website

Assignment of Commission

Commissions are to be paid/assigned to:*

Agent/Producer
Agency/Company

Commission statements are to be mailed to:*

Agent/Producer
Agency/Company

Assignee Information

Name of Person Responsible*

Email Address*

Please only enter a single email address.

Tax Class*

Tax ID #

Mailing Address (if different)

Street Address City State ZIP Code

Bank Information (Direct Deposit)

NOTE: Checks need to accrue to a total of $25 and direct deposit will need to accrue to a total of $5 before the commissions are issued. Your check will be deposited the second working day of each month and your statement will be sent via U.S. mail the second working day of each month.

Name on account*

Financial Institution*

Address

City State ZIP Code

Account Type*

Checking
Savings

Routing Number*

Account Number*

Errors & Omissions Insurance

Name of Carrier

Policy Name

Expiration Date*

Name of Insured

Policy Limits

Agent/Agency License

Please upload a copy of your agent/agency license

Attach E&O

NOTE: Files must be smaller than 1MB. A copy of your agent licensing (and agency if applicable) and a copy of your E&O is REQUIRED complete your application. If you are unable to upload copies of these, you may also email it to agentsupport@directbenefits.com or fax it to (651) 649-3502.

MWG will appoint agents in each state(s), as they sell their first case in that state, and its confirmed that their license is an active and valid license.

Questionaire

Where do you prefer to receive mail correspondence?*

Business
Home

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