Dealer application - Commercial Truck Dealers

Dealer application - Commercial Truck Dealers

Information about referrer
You refer as*
Select an Option
Entity name*
Address*
Street Address Address Line 2 City State ZIP Code
Title*
Primary contact name*
First Last
Primary Contact is only contact for the entity
Job Title*
Primary email*
Date entity established*
MM slash DD slash YYYY
- Mailing address is different than physical address
Mailing address*
Street Address Address Line 2 City State ZIP Code
Phone*
Fax
Additional contacts
Contact role First name Last name Email Phone

Please provide contact info for any personnel who will be contacting us on your company's behalf.
Compensation
Would you like to be compensated for referring?*
- Yes
- No

- I have changed my mind and don’t want to receive compensation for customers I refer
Referrer compensation
Receive compensation as*
Compensation receiver name*
Compensation receiver name*
First Last
SSN*
Based on the USA Patriot Act of 2001, we are required to identify all persons using our services.
The Social Security Number must match the receiver name.
FEIN (Tax ID)*
Based on the USA Patriot Act of 2001, we are required to identify all entities using our services.
The FEIN/Tax ID Number must match the company's name.
How would you like your referral compensations*
- Deposit to bank account
- Send by check
Deposit to bank account
Name on bank account*
Name on account must match compensation receiver name
Bank account*
Please upload a copy of voided check*
Drop files here or

Accepted file types: pdf, doc, docx, jpg, png, gif, Max. file size: 8 MB, Max. files: 1.
Bank routing number*
Bank Name*
This field is filled automatically after routing number check.
Bank City / State*
These fields are filled automatically after routing number check.
Send by check
Compensation Address*
Street Address Address Line 2 City State ZIP Code
- Same as primary address
- Same as primary address
- Same as mailing address

Referrer Agreement
This Referrer Agreement will be executed as of the Date of the first binding request by the Referrer.

Click here to read the agreement
Document upload*
Please upload your W9 Tax Form
W9 form to download
Drop files here or

Accepted file types: pdf, doc, docx, xls, xlsx, ppt, pptx, pps, jpg, png, gif, Max. file size: 8 MB, Max. files: 1.
Document upload*
Please upload your Driver's License Copy
Drop files here or

Accepted file types: pdf, doc, docx, xls, xlsx, ppt, pptx, pps, jpg, png, gif, Max. file size: 8 MB, Max. files: 1.
Contract will be executed only after receiving documents following documents:

• W9 Tax Form W9 form to download

You can send these documents by email documents@insurhaus.com or fax by 630-495-6039.
Please add your name in subject line

No compensation will be paid until required documents will be received and processed by Insurhaus Inc.
Contract will be executed only after receiving documents following documents:

• Driver's License Copy

You can send these documents by email documents@insurhaus.com or fax by 630-495-6039.
Please add your name in subject line

No compensation will be paid until required documents will be received and processed by Insurhaus Inc.
- I will send these documents to Insurhaus by e-mail or fax.
  * Please note, no compensation will be issued until required documents received.
Agreement confirmation*
- I have read and understand this agreement, and accept and agree to all of its terms and conditions.
Title*
Name*
First Last
Please sign*
Click here to Sign

Sign above
Comments
This field is for validation purposes and should be left unchanged.