Producer Documentation Checklist

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W-9 Information

1 Name of Entity/Individual(Required)

An entry is required. (For a sole proprietor or disregarded entity, enter the owner’s name on line 1, and enter the business/disregarded entity’s name on line 2.)

2 Business name/disregarded entity name

An entry is required if different from above

3a Check the appropriate box for federal tax classification of the entity/individual whose name is entered on line 1.(Required)

Individual/sole proprietor

C corporation

S corporation

Partnership

Trust/estate

LLC

Other

Check only one of the following seven boxes.

Enter the tax classification (C = C corporation, S = S corporation, P = Partnership)(Required)

C corporation

S corporation

Partnership

In the entry space, enter the appropriate code (C, S, or P) for the tax classification of the LLC, unless it is a disregarded entity. A disregarded entity should instead check the appropriate box for the tax classification of its owner.

3b Check this box if you have any foreign partners, owners, or beneficiaries

I foreign partners, owners, or beneficiaries

If on line 3a you checked “Partnership” or “Trust/estate,” or checked “LLC” and entered “P” as its tax classification, and you are providing this form to a partnership, trust, or estate in which you have an ownership interest

Other (From 3a)

4 Exemptions (codes apply only to certain entities, not individuals; see instructions on page 3):

Full PDF of W9 for reference.

Exempt payee code (if any)

Exemption from Foreign Account Tax Compliance Act (FATCA) reporting code (if any)

Applies to accounts maintained outside the United States.

5 & 6 Address(Required)

Street Address City State ZIP Code

7 List account number(s) here

optional

Part I Taxpayer Identification Number (TIN)

Enter your TIN in the appropriate box. The TIN provided must match the name given on line 1 to avoid backup withholding. For individuals, this is generally your social security number (SSN). However, for a resident alien, sole proprietor, or disregarded entity, see the instructions for Part I, later. For other entities, it is your employer identification number (EIN). If you do not have a number, see How to get a TIN, later.

NOTE: If the account is in more than one name, see the instructions for line 1. See also What Name and Number To Give the Requester for guidelines on whose number to enter.

Social Security or EIN?(Required)

Social Security

Employer identification number

Social Security(Required)

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First Part SS

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Second Part SS

This field is hidden when viewing the form

Last Part SS

Employer identification number(Required)

This field is hidden when viewing the form

First Part EIN

This field is hidden when viewing the form

Last Part EIN

Part II Certification

Signature(Required)

Date

ACH Information

Agency Information

Agency Name(Required)

Same Address as W9?

Yes

Agency Address(Required)

Street Address City State Zip

Street Address, City, State and Zip are all required fields.

Agency Phone(Required)

Direct Bill Bank Account Information

To be used for direct deposit of direct bill commission.

Type of Account(Required)

Checking

Savings

Select the type of account from the buttons above

Bank Name(Required)

ABA Routing Number(Required)

Must be 9 digits

Account Number(Required)

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ABA Routing Number 4 Digit

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Account Number 4 Digit

Name on Account(Required)

Agency Bill Bank Account Information

To be used for direct deposit of agency bill credit for premium return and/or agency bill commission.

Direct or Agency Bill(Required)

Use same bank account information as Direct Bill

I will supply separate bank account information for Agency Bill

Type of Account(Required)

Checking

Savings

Select the type of account from the buttons above

Bank Name(Required)

ABA Routing Number(Required)

Must be 9 digits

Account Number(Required)

This field is hidden when viewing the form

ABA Routing Number 4 Digit Agency(Required)

This field is hidden when viewing the form

Account Number 4 Digit Agency(Required)

Name on Account(Required)

Contact Info & Verification

Completed by(Required)

Full name of person completing this online form

Email(Required)

Last 4 of your Federal Tax Identification Number(Required)

Consent to EFT Deposit(Required)

I understand and consent

Thank you for providing banking information to be used for EFT direct deposit from Arlington/Roe. For verification purposes, you are asked to enter the last 4 digits of your agency’s Federal Tax Identification Number which must match our records. We also reserve the right to contact your agency in the event of discrepancies and/or concerns which may delay processing your request. We appreciate your understanding and cooperation as a partner of Arlington/Roe.

This field is hidden when viewing the form

Verification

Thank you for providing banking information to be used for EFT direct deposit from Arlington/Roe. For verification purposes, you will be asked to enter the last 4 digits of your agency’s Federal Tax Identification Number which must match our records. We also reserve the right to contact your agency in the event of discrepancies and/or concerns which may delay processing your request. We appreciate your understanding and cooperation as a partner of Arlington/Roe.

ePay

You are almost done setting up electronic payments to you, our agency partner!

We prefer to receive payments electronically as well. Electronic payments are more secure and efficient for everyone, which is why Electronic Funds Transfer (EFT) has become the standard rather than the exception. Currently, we receive over 70% of payments from our agency partners through our other electronic payment option, ePay.

Though paper check usage has dropped by 82% since 1993, check fraud has escalated and an estimated $24 billion has been lost in the last five years because of it. Using ePay to pay your monthly statement eliminates the risk of check fraud.

After completing this form, check out the flyer attached to your confirmation email for more information on how to get started with ePay.

Consent to EPay Information(Required)

I have read the above and consent

E&O (Minimum limit of $1 million is required)

E&O Document Upload(Required)

Drop files here or

Accepted file types: pdf, doc, docx, Max. file size: 60 MB, Max. files: 2.

Brokerage Agreement

You will receive a copy of the signed Brokerage Agreement following submission.

Full PDF of Brokerage Agreement for reference.

Consent to Brokerage Agreement(Required)

I have read the above and consent

By checking the box above, I acknowledge that I have fully read and agree to the terms of Arlington/Roe’s Brokerage Agreement.

Agency Name(Required)

Principal Signature(Required)

Principal Name(Required)

Title(Required)

This field is hidden when viewing the form

E-mail(Required)

Date

Confirmation

Confirmation Email(Required)

Include any additional email addresses that need to receive a copy of the confirmation email

Separate each address with commas

Becoming a Producer Documentation & Checklist

Documentation Checklist

W-9 Information

Part I Taxpayer Identification Number (TIN)

Part II Certification

ACH Information

Agency Information

Direct Bill Bank Account Information

Agency Bill Bank Account Information

Contact Info & Verification

Verification

ePay

E&O (Minimum limit of $1 million is required)

Brokerage Agreement

Confirmation