Brokerage Firm and Broker Contact Change Form Account Executive Name:(Required)Account Executive Email:(Required) Type of Change:(Required) Existing Brokerage Firm New Brokerage Firm Client Name:(Required)Does this change apply to additional verticals/accounts?(Required) Additional Verticals/Accounts Only named account above Additional Verticals/Accounts to Change:(Required)Existing Brokerage Firm Name:(Required)Type of Existing Brokerage Firm Change:(Required) ADD or REMOVE Broker Contact Update an Existing Broker Contact's Info (enter name and only info that is changing) Update the Brokerage Firm Info Where does this need to be updated?(Required) Acumatica and EAP Expert EAP Expert What Brokerage Firm info do you need to update? (check all that apply)(Required) Address Contract Changes for Existing Brokerage Firm New Brokerage Firm Name:(Required)New Address(Required) Street Address Address Line 2 City State AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific ZIP Code What contract changes are needed?(Required) Commission Rate Person Signing Contract Are they getting commission? Yes No New Commission Rate:(Required)Name of person signing contract:(Required) First Last Who should the contract be emailed to?(Required) How many broker contacts do you need to add?(Required)Please select...None1234Do you want these contacts to receive communications?(Required) Yes - they will be added under Org Contacts and will be sent the newsletter and benefit reminders. No Do you want these contacts to receive communications?(Required) Yes - they will be added under Org Contacts and will be sent the newsletter and benefit reminders. No ADD - Broker Contact Name(Required) First Last ADD - Broker Contact Email:(Required) ADD - Broker Contact Phone:ADD - 2nd Broker Contact Name:(Required) First Last ADD - 2nd Broker Contact Email:(Required) ADD - 2nd Broker Contact Phone:ADD - 3rd Broker Contact Name:(Required) First Last ADD - 3rd Broker Contact Email:(Required) ADD - 3rd Broker Contact Phone:ADD - 4th Broker Contact Name:(Required) First Last ADD - 4th Broker Contact Email:(Required) ADD - 4th Broker Contact Phone:How many broker contacts do you need to remove?(Required)Please select...None1234REMOVE - Broker Contact Name:(Required) First Last REMOVE - Broker Contact Email:(Required) REMOVE - 2nd Broker Contact Name:(Required) First Last REMOVE - 2nd Broker Contact Email:(Required) REMOVE - 3rd Broker Contact Name:(Required) First Last REMOVE - 3rd Broker Contact Email:(Required) REMOVE - 4th Broker Contact Name:(Required) First Last REMOVE - 4th Broker Contact Email:(Required) How many existing broker contacts do you need to update?(Required)Please select...1234Current Name(Required)New NameNew Email #2 Current Name(Required)#2 New Name#2 New Email #3 Current Name(Required)#3 New Name#3 New Email #4 Current Name(Required)#4 New Name#4 New Email
