Binder Request Business NameContact Name *Phone *Email AddressWebsiteBusiness Address *CityStateZip CodePlease Describe your Business. Please be specificHave you had any claims from your previous Policies. If Yes Please ExplainWhat Type of Insurance are you requesting?Authorization to gather & share information needed to shop, purchase, cancel new Insurance Policy per client consent and Standard Fee Agreement.I AgreeDisagree1. The parties to this agreement are (The Client),(The agent) JK's Affordable Insurance agency LLC Agent National Producer License Number 20410692 , and Universal Marketing and Management INC. an online search platform. 2. (The Client) appoints Agent as (The Client)'s insurance Agent of record. 3. This agreement shall become operative on the (Effective date) and shall continue in full force until terminated by either party.SubmitPlease do not fill in this field. Please do not fill in this field.
