Common use of Demographic Information Clause in Contracts

Demographic Information. Agency or Check here if you are NOT working with an agency Producer Name (Registered with IRS) (Legal Entity Name) (DBA Name—Optional) TIN -- Taxpayer Type: Corp Sole Prop. LLC LLP Other Entity Phone # ( ) - Ext. Fax # ( ) - Email Mail. Addr. c/o (Optional) (Street or PO Box) (City) (State) (ZIP) Bus. Addr. (Street—must be street address, no PO boxes) (City) (State) (ZIP) Licensing/Commissions Contact Name (Optional) Phone # ( ) - Ext. Fax # ( ) - Email Do you plan to assign commissions to an agency or an individual other than yourself? (If Yes, please complete the Compensation Assignment Form for the assignment to be effective.) Yes No