AGREEMENT entered into this _______ day of _________________________ by and
(City, State, Zip)
(hereinafter referred to as Broker) and Agency Resources of 190 River Road CN1011,
Summit, New Jersey 07902, hereinafter referred to as AR.
Whereas Broker desires to utilize the services of AR through PIA Management Services’
Number One Comp Program for placement of workers compensation business that AR
has with various insurance companies.
WHEREAS, AR agrees to extend such services to the Broker subject to the terms and
conditions set-forth below:
Broker warrants that it holds an insurance producer license issued by the State of
___________________ and all other licenses required to do business hereunder (copy of
license must be attached to this agreement) and that Broker intends to place business
through AR in compliance with the laws and regulations regarding the placement of
business with admitted carriers.
Broker acknowledges it is not the agent of and has no authority to bind AR or any
of its principals. Broker further warrants that it is the agent of the insured and
acknowledges that AR bears no agency responsibility to the insured.
AR will provide quotes to Broker on accounts submitted by Broker. Such quotes
will be valid for 10 days. If Broker accepts quotation, binder will be provided to Broker
by AR. Broker shall notify AR if quotation is acceptable within this 10-day period or
quotation will be withdrawn by AR.
Broker shall be entitled to receive a commission on such business placed with AR
at the commission rate as set forth on Schedule A which is attached to and made part of
this agreement on all new and renewal business.
Broker shall have the authority to issue Certificates of Insurance. At time of
issuance, Broker shall send copy of same to AR.
Broker shall not have authority to appoint other agents or subagents for purposes of
this agreement. Broker shall have no a