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Agency Mergers & Acquisitions Form

NOTE: This form needs to be completed twice, once by the seller and once by the buyer.

Agency Name:
Seller   /  Buyer 
FEIN Number:
Principal Contact:
Phone Number:
Email Address:
Primary Address:
City, State Zipcode:     
Broker Number(s):  ,  ,  ,  , 
Agency Contract, W9 on file: Yes      No 
Are All Seller Locations Remaining Operational? Yes      No 
Are Seller Fed ID & Legal Name Being Dissolved? Yes      No 
Policy Endorsements To This Address: Yes      No 
Until when?
New business policies to this address/code: Yes      No 
Billing/invoices to this address: Yes      No 
Any reps to be added/copied to this location/code? Yes      No 
Name, Phone/extension, Email:  ,  /  , 
Any reps to be deleted from this code/location? Yes      No 
Please List Rep(s) names:
Upload Current W-9:
(Only formats accepted, PDF, MSWord .DOC .DOCX)