Fill out W-9 and submit for our record.
Click here to download W-9 form.
Hereinafter referred to as "Broker" and Empire Underwriters, LLC., its successors and/or assigns, hereinafter referred to as "Empire". Broker desires to secure insurance coverage on behalf of his/her client ("Insured") through the facilities provided by Empire and Empire agrees to make facilities available to broker for placement of such insurance on the following terms and conditions.
IN WITNESS WHEREOF, the Parties acknowledge that each has carefully read this Agreement, that it has been fully explained to them by counsel of their choice, that they fully understand its binding effect, that the only promises made to them in signing this Agreement are those stated above, and that they are voluntarily signing this Agreement. This Agreement is hereby entered into as of the date first set forth above.