1. The full legal name of the Agency including DBA, if applicable.
2. The Agency's FEIN.
3. The Agency as a business entity must be registered with the Florida Division of Corporations in order to transact business or conduct its affairs in Florida. Refer to 607.1502(4), 617.1502(4), and 608.502(4) Florida Statutes for additional information. https://dos.myflorida.com/sunbiz/forms/
4. The Agency's license/registration number in Florida (resident or non-resident) for each location where the Agency is seeking to designate a producer.
   The Agency license/registration number is issued by the Florida Department of Financial Services (DFS), Division of Insurance Agent and Agency Services . For additional details concerning the Agency license and/or producer license, please contact DFS directly. A link to the DFS licensing database can be found on the FWCJUA's website under "Quick Links".
5. The physical address (business address) for each Agency location where the Agency is seeking to designate a producer.
6. For each AGENT IN CHARGE (AIC) of each Agency location where the Agency is seeking to designate a producer:
   
   1. Legal name
   2. valid SSN
   3. FL license number (resident or non-resident)
   4. direct email address
   5. direct phone number including any extension
   The AIC information for each Agency location is reflected under the Agency license/registration within the DFS licensing database.
7. For each PRODUCER the Agency is seeking to designate:
   
   1. Legal name
   2. valid SSN
   3. FL license number (resident or non-resident)
   4. direct email address
   5. direct phone number including any extension
   6. Name of a Florida licensed insurer actively writing workers compensation in FL for which he/she has an active appointment in FL.
   Insurer appointment information is maintained under each producer license within the DFS licensing database.
   NOTE: Designated producer(s) are the only Agency Representative(s) provided login credentials to the FWCJUA's Portal for application submissions.
8. For each CSR the Agency is seeking to have authorized to discuss specific accounts with the FWCJUA:
   
   1. Legal name
   2. FL license number (resident or non-resident)
   3. direct email address
   4. direct phone number including any extension
   5. name of direct supervising producer that the Agency is seeking to designate
   The Agency is not required to name a CSR; however, the FWCJUA will not speak to a CSR regarding specific FWCJUA accounts unless he/she is identified in the Agency Producer Agreement.
   NOTE: CSRs must be under the direct supervision of a Designated Producer at all times. Further, be aware that CSRs are not provided login credentials to the FWCJUA's Portal.
9. AGENCY OWNERSHIP: (complete as applicable)
   1. For each INDIVIDUAL OWNER/SHAREHOLDER/MEMBER:
      1. Legal name
      2. Title
      3. valid SSN
      4. direct email address
      5. ownership percentage
      6. direct phone number including any extension
   2. For each ENTITY OWNER:
      1. Legal name
      2. Title
      3. FEIN
      4. ownership percentage
      5. direct email address
      6. direct phone number including any extension
      7. ownership of the Entity Owner, in similar detail as requested for the Agency ownership
10. For the AGENCY PRINCIPAL that will sign the Agency Producer Agreement
    1. Legal name
    2. Title (owner or officer position)
    3. valid SSN
    4. direct email address
    5. ownership percentage, if any
    6. direct phone number including any extension
    NOTE: Documentation supporting that the listed Agency Principal is an owner/officer of the Agency may be requested to confirm that he/she is authorized to sign the Agency Producer Agreement on behalf of the Agency.
11. For the ONLINE ADMINISTRATOR the Agency is seeking to designate:
    1. Legal name
    2. direct email address
    3. direct phone number including any extension
    The Online Administrator is responsible for promptly reporting any changes to the Agency's information provided in the Agency Producer Agreement including, but not limited to, the Agency's ownership, Agents-In-Charge, Designated Producers and CSRs as well as the respective contact information for the Agency, its authorized locations and each such individual. Annually, the Online Administrator is also responsible for providing an updated Certificate of Insurance for the Agency's E&O or Professional Liability insurance in an amount no less than $500,000 per occurrence with an Insurer authorized to do business in FL that reflects the information required in 11.a below.
    NOTE: The Online Administrator is provided login credentials to the FWCJUA's Portal for administrative purposes only. Upon accessing the FWCJUA Portal, the Online Administrator is permitted to designate Online Admin Assistants, as desired.
12. Supporting Documentation:
    
    1. Certificate of Insurance evidencing Errors & Omissions (E&O) or Professional Liability insurance in an amount no less than $500,000 per occurrence with an Insurer authorized to do business in FL that reflects the following information:
       1. Certificate holder: FWCJUA, PO BOX 48957, SARASOTA, FL 34230
       2. Insurance type and coverage limits
       3. Issue date within the last 30 days
       4. Signed by an authorized representative of the Agency's insurer or broker
       5. Insurer representative contact name and phone number including any extension
       The FWCJUA will not accept a policy declaration page, a policy information page or a binder as evidence of the coverage.
       
    2. IRS Form W-9 for the Agency
    3. IRS Form W-9 for each Entity Owner of the Agency, as applicable
    4. A most recently filed federal tax form evidencing the ownership of the Agency that may include, but is not limited to, the following:
       1. IRS Form 1040, Schedule C
       2. IRS Form 1065, Schedule K-1
       3. IRS Form 1120, Schedule K
       4. IRS Form 1120, Schedule G
       5. IRS Form 1120-S, Schedule K-1
       6. IRS Form 1120-S, Schedule B-1
       7. IRS Form 851
    5. For each Entity Owner of the Agency, if any, a most recently filed federal tax form evidencing the ownership of the Entity Owner that may include, but is not limited to, the forms listed above in 11.d.

• The legal name of the Agency including the DBA name.
  
  
• The Agency's FEIN.
  
  
• The name, phone and direct email address of the person who you want to designate as the Online Administrator for the Agency.
  The Online Administrator will be responsible for promptly reporting any changes to the Agency's information provided in the Agency Producer Agreement including, but not limited to, the Agency's ownership, Agents-In-Charge, Designated Producers and CSRs as well as the respective contact information for the Agency, its authorized locations and each such individual. Annually, the Online Administrator will also be asked to provide the FWCJUA with an update on the Agency's Errors & Omissions (E & O) insurance or professional liability insurance.
  
  
• The name & direct email address of the Agency's principal that is requesting the Agency's authorization.
  
  
• The names of all Agency officers, senior managers, directors, partners and any persons who have the right to control 10% or more of the voting shares or other voting ownership interests of the Agency, including any and all of the Agency locations for which the Agency is seeking to designate a producer.
  
  
• The Agency's resident or non-resident license/registration number in Florida for each Agency location for which the Agency is seeking to designate a producer.
  
  
• The physical address and phone number for each Agency location for which the Agency is seeking to designate a producer.
  
  
• The name and direct email address of the "Agent in Charge" for each Agency location for which the Agency is seeking to designate a producer.   (This information is maintained under the Agency's license/registration number within the Florida Department of Financial Services, The Division of Insurance Agent & Agency Services licensing database.)
  
  
• The name, resident or non-resident license number, phone number, direct email address, social security number (SSN) and Agency location for each Producer that the Agency wishes to designate.
  
  
• The name, resident or non-resident license number, phone number, direct email address and Agency location for each CSR that will be supervised by a Designated Producer in conjunction with FWCJUA business.
  
  
• The name, phone number, direct email address, social security number and ownership percentage for each Agency Officer.
  
  
• The name of a Florida licensed Insurer actively writing workers compensation and employers liability insurance in the state of Florida for which the Agency or, individually, each Designated Producer serves as an appointed insurance agent or insurance agency that can be verified under the Agency's or each Designated Producer's Florida license/registration number.  (Appointment information is maintained under the Agency's license/registration number within the Florida Department of Financial Services, The Division of Insurance Agent & Agency Services licensing database.)
  
  

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