Agency Questionnaire - Agency Multiplied, Inc

Agency Information

Legal Name*

DBA's (Where Used)*

Main Address*

Street Address Address Line 2 City State ZIP Code

Main Phone Number*

Main Email*

Enter Email Confirm Email

Main Fax Number

Billing Information

Address*

Same as Main Address

Street Address Address Line 2 City State ZIP Code

Contact Person Legal*

First Last

Secondary Contact

First Last

Billing Phone*

Billing Email*

Enter Email Confirm Email

Billing Fax

Agency Logo

File

Divisions

Division Name

Division Address

Street Address Address Line 2 City State ZIP Code

Division Mailing Address

Same as Division Address

Street Address Address Line 2 City State ZIP Code

Are there additional divisions?

Yes
No

Division 2 Name

Division 2 Address

Street Address Address Line 2 City State ZIP Code

Division 2 Mailing Address

Same as Division Address

Street Address Address Line 2 City State ZIP Code

Division 3 Name

Division 3 Address

Street Address Address Line 2 City State ZIP Code

Division 3 Mailing Address

Same as Division Address

Street Address Address Line 2 City State ZIP Code

Users

Name*

First Last

Email*

Enter Email Confirm Email

Agency License*

Please Upload an Excel File(s) Listing License Information (Including License State, Number, Expiration)

Drop files here or

Division

Listed on Attorney-In-Fact?*

Yes
No

Are there additional users?

Yes
No

Name of User 2

First Last

Email of User 2

Enter Email Confirm Email

Licenses of User 2

Division of User 2

User 2 Listed on Attorney-In-Fact?

Yes
No

Name of User 3

First Last

Email of User 3

Enter Email Confirm Email

Licenses of User 3

Division of User 3

User 3 Listed on Attorney-In-Fact?

Yes
No

Are there additional users?

Yes
No

Name of User 4

First Last

Email of User 4

Enter Email Confirm Email

Licenses of User 4

Division of User 4

User 4 Listed on Attorney-In-Fact?

Yes
No

Name of User 5

First Last

Email of User 5

Enter Email Confirm Email

Licenses of User 5

Division of User 5

User 5 Listed on Attorney-In-Fact?

Yes
No

Would you like additional users?

Yes
No

IT Contacts

Website Contact Name*

First Last

Website Contact Email*

Enter Email Confirm Email

Website Contact Phone Number*

Is there a separate contact for technical issues?

Yes
No, same contact as Website

Technical Issues Contact Name*

First Last

Techinical Issues Contact Email*

Enter Email Confirm Email

Technical Issues Contact Phone Number*

Payment Contact Name*

First Last

Payment Contact Email*

Enter Email Confirm Email

Payment Contact Phone Number*

Merchant Account (Authorize.net Required)

Do you have a merchant account?

Yes
No

Would you like to set up a merchant account?

Yes
No

Do you want to accept electronic checks?

Yes
No

Agency Management System

Is your agency Management System hosted or internal?*

Hosted
Internal

What Agency Management System do you use?*

System Version*

Do you have web services?*

Yes
No

Other

Do you have any additional information you would like to include?