Doc Processing - Bind Request

Please use this form to submit any bind request. Only send this if client already signed and all monies were collected.

Name of the client (Company)
Customer ID
Producer Name Producer Name First Last
Coverages

Select the Coverages that are to be bound.
Coverages Selected

Coverages Selected Auto Liability Physical Damage Cargo Trailer Interchange General Liability Other Other
Effective Dates & Carriers

Select the Effective Dates only for the coverages to be bound.
Can we move the proposed effective date below up one day if needed?

Can we move the proposed effective date below up one day if needed? Yes No
If "No", please explain why Effective Date cannot change and must be honored.
AL - Carrier
AL - Effective Date AL - Effective Date / MM / DD YYYY
APD - Carrier
APD - Effective Date APD - Effective Date / MM / DD YYYY
MTC - Carrier
MTC - Effective Date MTC - Effective Date / MM / DD YYYY
TI - Carrier
TI - Effective Date TI - Effective Date / MM / DD YYYY
GL - Carrier
GL - Effective Date GL - Effective Date / MM / DD YYYY
Other - Carrier
Other - Effective Date Other - Effective Date / MM / DD YYYY
Payment Information

Provide the terms that were accepted by the client.
Down Payment $ Dollars . Cents
Number of Installments
Must be a number less than or equal to 11.
Payment Amount $ Dollars . Cents
Form of Payment

Form of Payment Cash Visa Mastercard American Express Wire Transfer Venmo / Zelle
Balance

Please make sure to update balance information in the IOI.
ACH

Recurring Payments
Is client enrolled in Automated Payments (ACH)?

Is client enrolled in Automated Payments (ACH)? Yes No
COI

Place the information for any Certificate Holder or Additional Insured requested.
Certificate Holder and AI's requested. If none, type "None"
Please upload a screenshot of the Payment Calculator as negotiated with the client. Please note that the Internals will be prepared according to the terms shown on the Screenshot attached.

Attach Files

Doc Processing - Bind Request

Doc Processing - Bind Request

Coverages

Effective Dates & Carriers

Payment Information

Balance

ACH

COI